We welcome you to Advanced Injury Treatment Center for your injury consultation and treatment.

This is your personal injury questionnaire. It can be time consuming and frustrating, but it is so important that all of this information is documented for your case. Take it bit by bit and don't let it overwhelm you!

Please bring a list of medications you are currently taking including pain medications and prescription medications with dosing instructions.

ABOUT OUR SERVICES:
Advanced Injury Treatment Center is a unique facility that offers a multidisciplinary approach to treating patients with auto injuries, workplace injuries and personal injuries under one roof. This coordinated approach allows for direct interaction between all providers involved in the patient’s care. By having direct communication, changes in a patient’s condition can be discussed and evaluated faster. Patients that are not progressing are not left drifting while they wait for their next medical appointment since providers have the ability to communicate face to face on a daily basis.  In addition to coordinated medical care, AITC provides comprehensive case management services for our patients ensuring they get the right care at the right time without having to deal with the complexities of the personal injury or worker’s compensation system.  Instead, the patient can focus on following their treatment plan and getting better.

Medication Policy: Advanced Injury Treatment Center’s medication policy prohibits the provision of any narcotic, habituating, or addictive medications after the acute phase of injuries related to your incident. We will provide you with a referral to a pain management specialist if long term pain management is required.

NO MEDICATIONS ARE FILLED AFTER OFFICE HOURS.

CONSENT TO TREAT

I understand the benefits and risks of physical therapy, massage therapy, personal training and pilates including, but not limited to, high velocity manipulation, mobilizations, internal mobilizations, electrical modalities, hot and cold modalities, and exercise programs. I will consult my practitioner with any questions or concerns immediately. I have stated all medical conditions I am aware of and will keep my practitioner informed of any changes. I, therefore, give my consent to be treated by any partner of Advanced Injury Treatment Center.

HIPAA NOTICE OF PRIVACY PRACTICES

Our HIPAA notice of privacy practices describes how medical information about you may be used and disclosed and how you can obtain access to any of your medical information. By initialing here, you acknowledge that you have reviewed our HIPAA policy.

HIPAA POLICY LINK 

CANCELLATION POLICY

At Advanced Injury Treatment Center, our goal is to provide you with the most advanced and effective medical services, physical therapy, and massage therapy available with one on one appointments. We strongly feel that individualized care is optimal and helps ensure your success in meeting your goals. As a result, we reserve space and staff time for your appointment. If you will be unable to make your scheduled appointment, please give us at least 24 hours notice so that we may fill your slot with another patient. Unfortunately, we must collect your credit card to charge a $25 dollar fee for any no-call no-show. This policy is ultimately up to the discretion of the treating provider. This fee will not be paid by your insurance company unless we are caring for a work-related injury in which case cancellation fee’s are charged based on the Colorado Worker’s Compensation allowances.

COMMUNICATION POLICY

Advanced Injury Treatment Center strives to protect ALL patient information, including your email address, phone number, etc. By providing your email address/phone number to us, you are giving us permission to send you appointment updates, occasional newsletters, informative articles, etc. We will NEVER sell or give out your personal information and you will always reserve the right to easily unsubscribe from our email list.

ASSIGNMENT OF BENEFITS AND FINANCIAL INFORMATION

Advanced Injury Treatment Center recognizes that there are multiple options for funding medical care after an auto accident. If you have questions regarding any of these options, we are happy to clarify the options for each individual. AITC does not accept medicaid, medicare, or private health insurance. AITC recognizes that you are not personally liable for any medical treatment in excess of your settlement, as such, you will never be billed personally except in the case that you breach our cancellation policy. By initialing here, you herby authorize and direct your insurance carrier(s), including financing for any medpay/bodily injury/auto insurance and workman’s compensation claim, to issue payment directly to Advanced Injury Treatment Center.

Advanced Injury Treatment Center, LLC, a Colorado limited liability company and its networked healthcare providers (collectively, “AITC”) and the above-named patient (“Patient”) agree as following regarding the above information and circumstances:

 
AITC hereby agrees to provide medical services and care to the Patient within the scope of AITC’s clinical practice for the Injuries suffered by Patient arising out of the above-described accident or incident and to delay payment for such charges under the terms of this Agreement in exchange for the Patient’s grant to AITC of the Lien, as defined below.  

Patient hereby agrees to grant and grants to AITC a health-care provider lien pursuant to Colorado Revised Statutes, §§ 38-27.5-101 through-108, to secure the payment of all medical care services provided to Patient by AITC for AITC’s treatment of Patient arising out of the above-described Injuries caused by the negligence or wrongful act of another person on any money received as a result of any Claims Patient has asserted or may assert on account of such Injuries against any third party or parties or under an uninsured or underinsured motorist insurance policy (the “Lien”).

AITC agrees that the charges for the medical services and care provided to the Patient under this Agreement underlying the Lien will be at the rate of its usual and customary billed charges, that such billed charges will not be excessive, unreasonable, or inflated and that such billed charges will not be subject to surcharges, finance charges, interest, or other increases in the amount of the Lien above AITC’s usual and customary billed charges.

AITC acknowledges and agrees that the maximum amount that may be collected under this Agreement and Lien by AITC or any assignee of the Lien is the total amount of AITC’s usual and customary billed charges for the medical services and care provided by AITC to Patient and that Patient is not liable for such billed charges if Patient does not receive a judgment, settlement, or payment on his or her claims against third parties or under an uninsured or underinsured motorist insurance policy for Patient’s Injuries and that Patient is not liable under this Agreement and the Lien for any amount in excess of the amount of any net judgment, settlement, or payment, as defined by C.R.S. §38-27.5-102(3),  on his or her claims against third parties or under an uninsured or underinsured motorist insurance policy for Patient’s Injuries. 

Patient represents to AITC that he or she is a resident of the state of Colorado and that, to the best of his or her knowledge, the above information as provided by Patient is true and accurate, that the Injuries are the result of the negligence or wrongful acts of the third parties identified above, and that Patient has no insurance in effect or for which he or she is eligible that would pay for the medical care and services to be provided by AITC under the terms of this Agreement.

 
Patient hereby authorizes AITC to publish notice of the Lien in the statutory lien records of the Colorado Secretary of State which notice will disclose Patient’s name and address, the fact of treatment by AITC, and any other information permitted or required by law concerning statutory liens and which notice and the information contained in it will be accessible to the general public by, among other means, an online computer search of the Colorado Secretary of State’s records. 

Patient further authorizes AITC and any assignee of the Lien to disclose and use all information, including, but not limited to, protected health information, concerning AITC’s care and treatment of and services provided to Patient concerning Patient’s Injuries arising from the foregoing accident or incident, which might include any medical history information that pre-dates the accident or incident, as convenient or necessary for AITC or any assignee of the Lien to enforce and collect on the Lien and to disclose the same information to the Patient’s legal counsel. Patient hereby authorizes his or her below described legal counsel to disclose to AITC any and all information related the Claims requested by AITC or any assignee of the Lien.

Statutory Disclosures:

The Following Disclosures To The Patient Are Required By Colorado Law (C.R.S. §38-27.5-104) And Should Be Carefully Reviewed By The Patient. If There Are Any Questions Or Concerns About The Disclosures, The Patient May Discuss Them With AITC And Should Consider Discussing Those Questions Or Concerns With Patient’s Legal Counsel.  

1. The following are potential methods for payment of billed medical charges (that may or may not be available to Patient):
   
   
   1. The creation of a health-care provider lien;
   2. The use of benefits available from any of the following payers of benefits for which Patient is a beneficiary (a person entitled to benefits) (although AITC does not accept any of the following):
      
      1. an insurer, such as a health insurer or workman’s compensation insurer;
      2. a health maintenance organization;
      3. a health benefit plan;
      4. a preferred provider organization;
      5. an employee benefit plan;
      6. a program of medical assistance under the "Colorado Medical Assistance Act", including Medicaid;
      7. the children’s basic health plan (for Colorado children that do not have health insurance);
      8. any other insurance policy or plan; or
      9. any other benefit available as a result of a contract entered into and paid for by or on behalf of Patient.
      10. Patient can obtain information about any available health-care provider network from the forgoing payers of benefits or AITC. 
   3. Any other payment method or arrangement agreed to in writing by both AITC, or its assignee, and Patient; or
   4. A combination of the payment methods specified in paragraphs (I)(A) through (I)(C), above.
2. AITC and any of its assignees of a health-care provider lien is not a health insurer or a payer of any benefits described in paragraphs (I)(B)(1) through (9), above;
3. Except in the event of fraud or misrepresentation by Patient:
   1. If Patient does not receive a judgment, settlement, or payment on his or her claim for injuries against third parties or under an uninsured or underinsured motorist policy, Patient is not liable to AITC or any assignees of the health-care provider lien (known as the holder of the health-care provider lien) for any portion of the health-care provider lien;
   2. If Patient receives a net judgment, settlement, or payment that is less than the full amount of the health-care provider lien, the injured person is not liable to the holder of the health-care provider lien for any amount beyond the net judgment, settlement, or payment, and the holder of the health-care provider lien may not file a claim (a complaint or counterclaim) against Patient directly to be reimbursed for any amount beyond the net judgment, settlement, or payment. Nothing in this section prevents a health-care provider or its assignee from initiating a declaratory judgment action or participating in an interpleader action or claim pursuant to the Colorado rules of civil procedure, or any other similar action or claim, to determine the Health-care provider's or its assignee's share of the injured person's net judgment, settlement, or payment.
   3. The health-care provider or its assignee may not assign a health-care provider lien to a collection agency or debt collector;
4. AITC’s assignee's compensation from the Patient is based on the difference between AITC's usual and customary billed charges and the amount that the assignee pays to purchase the health-care provider lien;
5. There is no common ownership interest between the holder of the health-care provider lien and Patient’s legal counsel;
6. There is no common ownership interest between any assignee of the health-care provider lien and AITC or any other health care provider who is providing treatment or who may provide treatment to Patient under the terms of the health-care provider lien, although if any person or entity takes assignment of the health-care provider lien, it may retain Continuity of Care Colorado, LLC (“CCC”) to manage and collect the health-care provider lien and AITC and CCC have common ownership. 
7. If Patient has obtained health insurance even after a health-care provider lien has been created, and Patient or Patient’s legal counsel so informs the holder of the health-care provider lien, all future care may be billed to the health insurance carrier at the injured person's discretion.
8. Upon request by Patient or Patient’s legal counsel, the holder of the health-care provider lien shall provide in writing to the Patient an itemized statement of all the billed charges for treatment comprising the total value of the health-care provider lien as the billed charges are accrued, to the extent practicable, and when the health-care provider lien is final. The final itemized statement must include a summary of all treatments provided, the total amounts billed for each treatment, and the total amount of the health-care provider lien due and owing.

The Patient May Discuss Any Questions Or Concerns About The Disclosures With AITC And Should Consider Discussing Those Questions Or Concerns With Patient’s Legal Counsel.  

Statutory Limits on Health-care Provider Liens
Colorado Revised Statutes, §38-27.5-105, imposes certain limitations on what a health-care provider or its assignee may charge or do with respect to a health-care provider lien (the “Statutory Limitations”).  AITC acknowledges and agrees that the Lien is subject to the Statutory Limitations and that AITC and any assignees of the Lien are obligated to act regarding the Lien, including, but not limited to, in enforcing the Lien, in compliance with the Statutory Limitations. 

   
Patient acknowledges and agrees that AITC may assign or sell the Lien to a third party which is not a collection agency or debt collector. No such assignment or sale by AITC will change any of the terms or limitations on the holder of the Lien (AITC or its assignee or purchaser) concerning amounts that can be collected under the Lien or any other term of this Agreement.

By Signing This Agreement, Patient Acknowledges That The Information In This Agreement Will Become Public, And That The Health Care Information AITC Maintains Concerning The Patient’s Medical Care Covered Under The Lien May Be Disclosed To A Third-Party Purchaser Of Patient’s Lien.

I AUTHORIZE THE RELEASE OF THE FOLLOWING MEDICAL INFORMATION FROM THE FOLLOWING TREATMENT FACILITIES I WENT TO AFTER MY ACCIDENT:

MY RIGHTS

• I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate
  disclosing party.
• I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I AUTHORIZE ADVANCED INJURY TREATMENT CENTER TO RELEASE MY MEDICAL RECORDS TO THE FOLLOWING: 

MY RIGHTS

• I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.
• I understand that uses and disclosures already made based upon my original permission cannot be taken back.
• I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.
• I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.
• I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.