Please answer all the questions completely. All information provided is strictly confidential. If you do not understand a question or are unsure of the information, please ask for assistance.
Please draw lines from the body regions on the left side and match to the right side.
ALL TYPES OF COLLISIONS (Indicate those relevant to you)
SEATBELT USAGE AND STEERING WHEEL HAND PLACEMENT
REAR-END COLLISIONS ONLY (Answer this section only if you were hit from the rear)
BRUISING AFTER THE ACCIDENT
EMERGENCY ROOM AND DISABILITY DATES
DISABILITY: HAVE YOU BEEN ABLE TO WORK SINCE INJURY?
It is important for this section to be filled out in detail. Look at each symptom listed on the left column and make a single check mark or several check marks in the appropriate columns for the specific symptom which applies to you. Be certain to indicate when you had the beginning of any of the following symptoms. Leave the row blank if the symptom does not apply to you.
List any operations, surgeries, or medical procedures:
PROVIDERS SEEN SINCE INJURY OR WHEN CONDITION BEGAN
Start with the first doctor you went to after your injury or condition began and list all providers (all types of doctors or therapists) up to your last provider seen and check all that apply for each. Be certain to list these in sequence form first to last.
1Name Emergency Room, hospital / doctor / therapist / Center
2Name Emergency Room, hospital / doctor / therapist / Center
Thank you for completing this questionnaire and intake form regarding your recent accident and injury. The information provided will help us create the most effective treatment plan for your rapid recovery.
Son Nguyen, PLLC7560 Red Bug Lake Road, Suite 1080Oviedo, FL 32765407-977-2240 ** 407-977-2446 fax
ASSIGNMENT OF BENEFITS
I hereby assign any and all automobile insurance policies which provide medical benefits, rights, title and interest to Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee), for payment of services rendered unto me both by reason of accident or illness. This is to act as an assignment of my rights and benefits to the extent of the Assignee’s services provided.
ASSIGNMENT OF CAUSE OF ACTION
In the event my insurance company fails to pay Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee) the full amount due and owing to Assignee after notice is given, I hereby assign and transfer to Assignee any and all causes of action, and proceeds from such causes of action, that I might have or that might exist in my favor against such company and authorize Assignee to prosecute said cause of action either in my name or Assignee’s name and further I authorize Assignee to compromise, settler or otherwise resolve said claim or cause of action as they see fit.
DIRECTION OF PAYMENT
I hereby authorize my or any insurance company or attorney to pay directly to Assignee the amount of this and/or any future bills for services rendered to me. I also agree to pay in a current manner any difference between the total charges and the amount paid by the insurance company directly to Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee). In the event that I do not have insurance coverage, I understand that I remain personally responsible for payments or services rendered. I hereby further give an irrevocable lien to said Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee) against any and all insurance benefits names herein and any and all proceeds of any settlement judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee).
PIP LOG REQUEST
I hereby authorize Assignee to release any infor mation requested that is pertinent to my case to my insurance company or attorney involved in this case. Pursuant to 627.4137 Florida Statutes (2001), I hereby request a copy of the Pip Log and Declaration Sheet, which reflects the policy limits available at the time of this accident, to be provided to Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee), I hereby authorize Seminole Chiropractic Medicine / Dr. Son Nguyen (Assignee) to request and receive a copy of my Pip log periodically as they deem to be necessary.
RESERVATION OF BENEFITS
Please be advised that I am hereby placing you on notice that, pursuant to Florida case law, should you deny, reduce or fail to pay either a portion of or an entire bill submitted on my behalf from this healthcare provider. I am requesting that you reserve, or hold aside, that same amount until this dispute is resolved. If any term of this assignment or the application thereof to any person or circumstances shall be determined invalid or unenforceable the remainder of this assignment shall not be affected thereby, and each term and provision of this assignment shall be valid and to the fullest extent of the law.
I HEREBY AUTHORIZE and direct
Insurance Company to pay by check made payable to and mailed directly to Dr. Son Nguyen; 7560 Red Bug Lake Road, Suite 1080, Oviedo, FL 32765, the medical and professional expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered by the above-named medical provider. This payment will not exceed my indebtedness to the above-mentioned medical services provider. I understand that I remain personally liable for, and agree to pay in a timely manner, any balance of said professional service charges over and above this insurance payment. I further understand that such payment is not contingent upon any settlement claim or verdict, by which, I may recover said fee. If my current policy prohibits direct payment to my medical services provider, then I hereby instruct and direct you to make the check payable to me and DR. SON NGUYEN(medical care provider), and mail it to the above listed address.
I authorize the above-mentioned office to, and hereby give power of attorney to, said office to endorse/sign my name on any and all checks for payment of medical services received from my insurance company for medical services provided by said office and grant a lien to said medical services provider for any proceeds of insurance benefits payable under my policy.
Furthermore, I, the undersigned patient, hereby irrevocably make, constitute and appoint Dr. Sion Nguyen (medical care provider) and any person designated by Dr. Son Nguyen (medical care provider) as my special attorney-in-fact and agent, with full power:
All previous assignments, authorizations and records release agreements entered into between the parties are hereby rescinded, repealed and otherwise null and void as if I never entered into, effective immediately. This instrument is not intended to operate as an assignment as that term is used in Florida Statutes 627.756 and any provision(s) of this instrument that may be interpreted as such shall be considered null and void from the beginning and the remaining provision(s) of this instrument shall be served from said provision(s) and will remain in full force, effect and operation.
A photocopy of this instrument shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to the insurance company and its adjuster to the extent necessary to obtain payment for medical services.
As a result of the changes to the 2003 Florida No Fault Statute (PIP Statute), it is a third degree felony for any health care provider to agree to waive your co-payment (if applicable) as a routine business practice.
We therefore require payment of all balances due, whether co-payments or deductibles, after all attempts by us (including litigation) to collect from the PIP (insurance company) carrier and the at fault driver’s carrier have been exhausted.
Two exceptions are permitted under the law:
Please speak with our billing manager if you have any questions.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition, and related health care services.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for he purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related serv ices. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, yo ur protected hea lth information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for y our health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use o r disclose, as - needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, em ployee review activities, training of med ical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may u se a sign - in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information a s necessary to c ontact you to remind you of your appointment.
We may use or disclose your protected health information in the following situation without your authorization. These situat ions include: as Required By Law, Public Health issues as required by law, Communica ble Diseases: Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroner, Funeral Directors, and Organ Donation , Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures, Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Secti on 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.
17 You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights : Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, crim inal, or administrative act ion or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction on your protected health information. This means you may ask us not to use or di sclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your dare or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specifi c restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restrictio n that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information , your protected health information will not be restricted. You then have the right to use another Healthcare Profe ssional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept th is notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints : You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights hav e been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003
We are req uired by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Co mplian ce Officer in person or by phone at our main phone number.
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:
What is PIP?
Personal Injury Protection, or simply PIP, is mandatory medical coverage provided by your own auto insurance company in the event of an accident. Because PIP is applicable even if you are at fault, it is sometimes also referred to as “no - fault insurance.”
PIP is governed by Florida Statute Sec. 627.736(1). Pursuant to this statute, an insurance company is required to provide their insured with a minimum of coverage should they be involved in an auto - accident. The minimum coverage is $10,000 per person, and it will cover or reimburse the following expenses:
If you do not have an “emergency medical condition,” you will not be able to receive more than $2,500 in benefits. Florida law defines “emergency medical condition” as a medical condition that requires immediate medical attention and could reasonably be expected to result in serious jeopardy to the patient’s health. A medical doctor will need to determine whether you qualify for this condition. If you qualify for this condition, you can receive up to the $10,00 0 limits of coverage.
Who qualifies for PIP?
When involved in an auto - accident, regardless of who is at fault, every person involved will report to their own insurance company for PIP benefits. If you are not covered on an auto - insurance policy you may st ill qualify for PIP through other means such as residing with a relative who owns an insured vehicle, or riding in a vehicle that is insured.
You must seek treatment within 14 days of an auto accident to qualify for PIP coverage. Failure to seek treatme nt during this time period disqualifies you from receiving PIP benefits.
Do I have to use PIP?
Many people do not want their own insurance company to pay for treatment when another party was at fault. However, the law requires that PIP be used, as it is considered primary insurance coverage for medical treatment following an auto accident in Florida. You have paid for PIP coverage as part of the premium; and built into that premium cost is the consideration that PIP is used no matter who is at fault.
Can I use PIP if I am at fault for the accident?
If you are injured in an accident, you can use PIP benefits no matter who was at fault for the accident.
Why can’t I use health insurance?
Some people inquire why they should use their PIP insurance when th ey have health insurance. Under existing law, PIP is considered primary coverage for medical treatment following an auto accident. If PIP is applicable, most health insurers will not pay for treatment until the PIP benefits have been exhausted. Additio nally, when your PIP provider makes payments, you are never required to reimburse the PIP insurer for these payments if you receive a recovery from another party. However, most health insurers have a right of subrogation where they are allowed to recover what they have paid.
Who pays for the balance of the bills?
PIP will only pay 80% of any medical bill. The remainder of the bill remains your responsibility. These outstanding balances constitute “out - of - pocket expenses”. These can be claimed as damage s against the at - fault party. There may be other forms of coverage available to cover the remaining balance including Health Insurance, Medical Payment Auto Coverage, Medicaid or Medicare.
If you make a claim against the at fault insurer, this insurer may pay for the 20% balance that has not been paid by PIP insurance. In our experience, the insurer does not pay the balance until you or an attorney makes a demand for the balance. The insurance company will not pay the 20% balance after each visit. We a re also aware that insurance companies have advised our patients that they will pay the 20% balance only to later state that they will only pay a portion of the balance, due to some claimed issue by the insurer. This is one of the reasons we sometimes rec ommend that you seek counsel who can best protect you.
How do I handle my medical bills?
While you are focusing on recovering and getting better, our office will handle the processing of your medical bills. We will submit the bills to your PIP insurer, and your insurer will directly reimburse our office for the treatment. As a reminder, we are not fully reimbursed for the treatment since PIP only pays 80% of the bill.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x - rays, on me (or o n the patient named below, for whom I am legally responsible) by Dr . Son Nguyen and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back - up for Dr. Son Nguyen, including those working at the clinic or office listed below or any other o ffice or clinic.
I will have/had an opportunity to discuss with Dr. Son Nguyen and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disk injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complicat ions, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I understand that I have the right to seek other healthcare profes sionals for my condition and treatment.
This is to confirm that I have been advised by the Doctor that x - rays can be ha zardous to an unborn child. At this time, to the best of my knowledge, I am not pregnant, and I consent to chiropractic treatment and radiographic pictures.
I hereby authorize the Doctor to examine and treat as deemed necessary,
(indicate your relationship to the child).
(Seminole Chiropractic Medicine)7560 Red Bug Lake Road, Suite 1080Oviedo, FL 32765407-977-2240
Dr. Son Nguyen is requesting a Letter of Protection for your outstanding balance.
This letter would authorize your attorney, in the event of settlement, to pay the entire outstanding balance or a negotiated amount, with Dr. Son Nguyen prior to your receiving any settlement proceeds.
In the event that a settlement is not reached, for whatever reason, the bill would be submitted to your medical insurance company and you will be responsible for the regular co - pay and any “patient responsibility” amount indicated by your medical provider.
Please be advised that we may or may not be willing to make an appointment or treat you should y ou decide not to follow the prescribed treatment of care, and without the letter of protection protecting our future outstanding balance.
By signing below you authorize your attorney to communicate with Dr. Son Nguyen, PLLC, regarding your injuries and av ailable insurance monies in the case should we request the same.
I DO authorize
to provide a letter of protection to the above indicated health care provider.
I DO NOT authorize
Dr. Son Nguyen, PLLC7560 Red Bug Lake Road, Suite 1080Oviedo, FL 32765Ph: 407-977-2240Fax: 407-977-2446
I hereby authorize an d direct you, my attorney, pursuant to Florida Statute F>S. 627.422 to pay directly to the above named provider such sums as may be due and owing them for professional services rendered to me by them. I also direct you to withhold any such sums or balance thereof that may be due to the above named provider from any settlement, judgment, payment, or verdict which may be paid to you, my attorney or me as the result of the injuries for which I have been treated.
I fully understand that I am directly and full y responsible to the above named provider for all bills submitted by them for services rendered to me by them. And that this agreement is made solely as additional protection for any balance owed to them. I further understand that such payment is not conti ngent on any settlement, judgment, payment or verdict by which I may re over said payment.
I hereby acknowledge that this Provider’s Lien is irrevocable and may not be terminated, ignored or subjectively complied to without the expressed written consent of the Provider.
The undersigned hereby acknowledges that I have read and understand the above information. I am signing without any threat of coercion, force or against my will. I am signing freely, voluntarily and with my full consent.
DR. SON NGUYEN, PLLC
7560 RED BUG LAKE ROAD, SUITE 1080, OVIEDO, FL 32765
407-977-2240 ** 407-977-2446 (Fax)
AUTHORIZATION TO OBTAIN, RELEASE OR REVIEW PROTECTED HEALTH INFORMATION
I hereby authorize
use and disclose to:
I understand that this authorization extends to all or any part of the records designated above, which may include psychiatric information, and/or genetic counseling/testing, and/or alcohol/drug abuse an d/or AIDS (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test or the fact that an HIV test was performed. I expressly consent to the release of information as designated above unless initialed below or otherwise required by law.
If I fail to specify an expiration event or condition, the authorization will expire in one year. I understand that this authorization is revocable upon written notice to the office where the original authorization is retained, except to the extent that a ction has already been taken on this authorization. I understand that my protected health information that is used or disclosed under this authorization may be subject to re - disclosure by the recipient and the privacy of my protected health information ma y no longer be protected by law. I further understand that Seminole Chiropractic Medicine / Dr. Son Nguyen, DC my not condition the provision of treatment, payment, enrollment in the health plan, or eligibility for benefits on the provision of this author ization. I understand that I will receive a signed copy of this form.