This allows our patients to achieve far ... - Chiropractorchiropalmbeach.com/wp-content/uploads/2016/08/Personal-Injury-Ne… · I give Palm Beach Chiropractic & Rehabilitation

Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449

Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]

WELCOME TO OUR OFFICE

We specialize in assisting our patients to achieve their

highest level of health through our evidenced-based treatment

protocol. Our approach is very unique and advanced from other

chiropractic office programs. This allows our patients to

achieve far superior results compared to most other systems.

Please fill out the following information thoroughly so the

doctor can let you know if you are a case we can accept. Please

feel free to ask any questions if you need assistance. We look

forward to serving you.



New Patient Information

Name:___________________________________________________________________________

Date of Birth:____________________________

Home phone:_____________________________ Work phone: ___________________________

Cell phone: _____________________________

Address:__________________________________________________________________________

City, St, Zip_______________________________________________________________________

What is your Native Language?______________________________________________________

Emergency contact/Relationship ____________________phone____________________________

Email: (Please print clearly.)_________________________________________________________

Occupation:_______________________________________________________________________

Who is your primary care physician? _________________________________________________

May we have permission to contact your physician regarding your case? ( ) Yes ( ) No

How did you hear about us? _________________________________________________________

Have you ever been to a Chiropractor before? ( ) Yes ( ) No.

I give Palm Beach Chiropractic & Rehabilitation, Inc. and its representative’s permission to communicate

to me via the contact information above.

___________________________________________________ _____________________

Signature Date

** Standard Assignment and Release **

I assign and authorize my insurance benefits to be paid directly to Palm Beach Chiropractic &

Rehabilitation. I understand that I am financially responsible for any balance incurred for services

rendered, except in the case of worker’s compensation and contractual write-offs. I waive any statutory

time limitations for collecting any amount due and authorize Palm Beach Chiropractic & Rehabilitation to

release any information necessary to process my claims.

___________________________________________________ _____________________

Signature of Insured Date



Informed Consent for Chiropractic Treatment

All medical procedures have potential side effects and complications. While the risk of serious

complication resulting from the procedures utilized in this office is extremely small, we feel it is

important for you to be fully informed prior to proceeding with our care.

Prior to any treatment being provided in this office a physical examination will be undertaken in which

your body will be moved in different directions to determine where the pain is coming from. This can

result in residual pain or soreness.

The primary treatments used by the chiropractic physicians in this office are various types of manual

techniques (manipulation, mobilization) and various types of exercise. In approximately 1/3 of patients

who are treated with manipulation, increased pain results, usually after the first or second treatment.

This is mild or moderate in 90% of cases and almost always resolves within 48 hours. In rare cases, rib

fractures have been known to occur. No treatment will be provided until an examination is performed,

a diagnosis is made and a discussion of our findings and recommendations is undertaken.

There are rare reported cases of disc injuries identified following manipulation, although no scientific

evidence has demonstrated such injuries are caused, or may be caused, by manipulation. However,

there are uncommon cases in which a pre-existing disc herniation may become aggravated.

There are reported cases of stroke associated with visits to both medical physicians and chiropractic

physicians. Research and scientific evidence does not establish a cause and effect relationship between

manipulation and the occurrence of stroke. Recent studies suggest that patients may be consulting

medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a

stroke already in progress. However, you are being informed of this reported association because a

stroke may cause serious neurological impairment or even death. The possibility of such injuries

occurring in association with upper cervical manipulation is extremely remote.

Other treatment options outside this office may include, over-the-counter analgesics and rest, medical

care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers, injections or

surgery.

If you chose to use one of the above noted “other treatment” options, you should be aware that there

are risks and benefits of such options and you may wish to discuss these with your primary medical

physician.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a

pain reaction further reducing mobility. Over time this process may complicate treatment making it

more difficult and less effective the longer it is postponed.

By signing below I state that I have weighed the risks involved in undergoing treatment and have

decided that it is in my best interest to undergo the treatment recommended. Having been informed of

the risks, I hereby give my consent to that treatment.

Signature:_______________________________________________________ Date: ____/____/____



PATIENT CONSENT FORM

(HIPAA)

I understand that I have certain rights to privacy regarding my protected health information. These rights

are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I

understand that by signing this consent I authorize you to use and disclose my protected health

information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my

treatment)

Obtaining payment from third party payers (e.g. my insurance company)

The day to day healthcare operations of your practice

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy

Practices, which contains a more complete description of the uses and disclosures of my protected health

information, and my rights under HIPAA. I understand that you reserve the right to change the terms of

this notice from time to time and that I may contact you at any time to obtain the most current copy of this

notice.

I understand that I have the right to request restrictions on how my protected health information is used

and disclosed to carry out treatment, payment, and health care operations, but that you are not required to

agree to these requested restrictions.

However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that

occurred prior to the date I revoke this consent is not affected.

Date:________________________________________

Print Patient Name: _____________________________

Relationship to Patient: __________________________

Signature: ____________________________________



Travis Lamperski, D.C.

Power of Attorney and Medical Release

POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILL ENHANCE

OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES REDERED, INCLUDING BUT NOT LIMITED TO A

RELEASE OF MEDICAL RECORDS AND ASSIGNMENT OF BENEFITS/AUTHORIZATION TO PAY.

Know by all these present that: The undersigned has made, constituted and appointed, and by these presents does hereby make,

constitute and appoint TRAVIS LAMPERSKI, D.C., and any of its duly authorized agents and employees as and to be the

undersigned’s true and lawful attorney for and in the undersigned’s name place and stead to endorse any and all checks, drafts or

money orders which are made payable to the undersigned alone or to the undersigned and the said TRAVIS LAMPERSKI, D.C.,

which checks, drafts or money orders are made payable for services which have been made by TRAVIS LAMPERSKI, D.C., at

the request or with the knowledge and approval for the undersigned and or the maker of the check, draft of money order.

Furthermore, the undersigned allows TRAVIS LAMPERSKI, D.C., or any of its agents to sign any paper that will be necessary

to enhance, expedite and/or allow payment to said provider. This may include affidavits of non-ownership of vehicles, insurance

forms and other statements.

The undersigned by these presents does give and grant the said TRAVIS LAMPERSKI, D.C., as attorney the full power and

authority to do and perform all and every act whatsoever requisite and necessary to be done in and about the premises as fully to

all intents and purposes as the undersigned might or could do to personally present insofar as the endorsing and cashing of said

checks are concerned as well as any other document.

Medical Release

A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services or

supplies pertaining to me to release true copies of the same to TRAVIS LAMPERSKI, D.C., or any insurer providing coverage to

me in connection with the processing of any claim for benefits made by me or by the assigned herein. A photocopy of this

document shall be as binding as an original signature page.

The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this special

power and which the said attorney shall do or cause to be done by virtue of these presents.

Assignment of Benefits

I, ___________________________________ Hereby authorize, __________________________________________________

(Name of Insured Patient) (Name of Insurance Carrier)

to make medical payments otherwise payable to me for services rendered by TRAVIS LAMPERSKI, D.C., but not to exceed the

charges of those services, payable to and mailed directly to:

TRAVIS LAMPERSKI, D.C.

5500 S. STATED RD. 7 SUITE 112

LAKE WORTH, FL 33449

Furthermore, I HEREBY IRREVOCABLY assign to TRAVIS LAMPERSKI, D.C., the rights and benefits under any policy of

insurance, indemnity agreement, or any other collateral source as defined in Florida Statues for any service and/or charges

provided by TRAVIS LAMPERSKI, D.C.

IN WITNES WHEREOF the undersigned have hereunto set their hands, this ____________ day of ______________,20____

_________________________________ ____________________________________

PATIENT SIGNATURE PATIENT’S NAME (Please Print)



Personal Injury Questionnaire (Auto Accident)

Name:__________________________________________ Date (today):___________________

Have you filed a claim with the insurance company? NO YES Claim #:________________

Date of Accident:_____________ Where did the accident happen? Describe in your own words:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

What was your position in the car?

Driver: Were your hands on the steering wheel? Left Right Both

Passenger: Where were you seated? Front Right Rear Left Rear?

Did your vehicle strike another vehicle? NO YES

Angles of impact….First Impact: Front Rear Left Right

Second Impact: Front Rear Left Right

Were you wearing your seatbelt? NO YES

Did you brace for impact? NO YES I braced with my hands I braced with my feet

Which way were you facing at the time of impact? Straight ahead Left Right

Did YOU strike anything in the vehicle at the time of impact? NO YES

If YES, specify what part of your body struck what: ie… head, chest, shoulder/knee right/left

Steering Wheel_____________________ Dashboard____________________________

Windshield_________________________ Roof_________________________________

Left Side Door______________________ Right Side Door _______________________

Left Window_______________________ Right Window_________________________

Other______________________________________________________________________

Did the seat back bend / break? NO YES

Immediately following the accident. How did you feel? dizzy/dazed disoriented

nervous nauseous upset weak other________________________

Did you lose consciousness? NO YES

Did you go to the hospital? NO YES Were you admitted? NO YES

If YES, how long?______________

If you went to the hospital, when? At time of accident Next day

How did you get to the hospital? Ambulance Police car Private Transportation

Name of hospital:_______________________________________________________________

Attended by Dr. ________________________________________________________________

Have you seen any other doctor as a result of this accident? NO YES

Who?________________________________________________________________________



What treatment was given?

None placed in a brace X-ray/MRI/CT: ________ given stretches bandaged

given pain medication given instructions regarding concussion physical therapy

given instructions regarding sprain & strain referred to orthopedic surgeon / PCP

referred to this office for treatment Other____________________________________

CHIEF Complaints or Symptoms:

Neck Pain, with pain radiating into: none left shoulder left arm left forearm

left hand right shoulder right arm right forearm right hand

YOU are also experiencing: Headache Migraine Headache Upper back pain

Ringing in the ears: NO YES Left Right Both Ears

Blurry Vision: NO YES Left Right Both Eyes

Wrist Pain: NO YES Left Right Both Wrists

Jaw Pain: NO YES Left Right Both Sides

dizziness nervousness fatigue anxiety depression excessive irritability

fear of driving in a car a loss of concentration jaw clenching teeth grinding

nightmares difficulty with sleeping at night other:_________________________

Low Back Pain, with pain radiating into: no radiating pain left buttock left thigh

left knee left foot right buttock right thigh right knee right foot

Hip Pain: Left Right Bilateral

Knee Pain: Left Right Bilateral

Foot/Ankle Pain Left Right Bilateral

Numbness: NO YES, Where? _______________________________________________

Tingling: NO YES, Where? _______________________________________________

Additional Symptoms / Complaints: ________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Have you lost any time at work due to your injuries? NO YES Dates:_______to_______

Have you had any previous injuries or accidents? NO YES

Description of Accident/Injuries:___________________________________________________

How much better did you feel prior to your current condition? (Ex: 100%, 80% etc):_________%

I give Palm Beach Chiropractic & Rehabilitation, Inc. and its representative’s permission to

communicate to me via the contact information provided.

Signature:__________________________________________ Date: _____________________



Authorization for release of healthcare provider medical records and billing information.

Patients Name______________________________ Phone # _______________________

Date of Birth ______________________________

I hereby authorize Palm Beach Chiropractic & Rehabilitation, Inc. to disclose the following health

information to:

Name: __________________________________________

Phone # __________________Fax #___________________

Address:____________________________________________________________________________

I hereby authorize (name & phone #)____________________________________________________

to disclose the following health information to Palm Beach Chiropractic & Rehabilitation, 5500 S.

State Rd. 7 Suite 112, Lake Worth FL 33449. Phone (561) 708-5700 Fax (561) 708-5750

E-mail: [email protected] (E-mail X-RAYS and Records if possible please)

Information to be released must be checked: (please be specific)

_____ the entire medical record _____ follow-up/progress notes

_____ history and physical _____ referral letters and consults

_____ operative notes _____ admission/discharge summary

_____ MRI, X-ray, lab reports, etc _____ billing statements

_____ physical therapy notes _____ other ____________________

For dates of service: _______________________________________________________

To the extent applicable, I understand that my medical record may contain information that is considered

sensitive in nature under the law. My check marks below indicate(s) that I do NOT permit

information of this type, if it exists, to be released. If I do not check any boxes all such information will

be released.

HIV/AIDS Sexually Transmitted Diseases Treatment for Drug and/or Alcohol

I understand that this authorization will expire one year from the date of signing unless a shorter time

period is indicated. I understand that I may revoke this authorization at any time by writing to the medical

provider identified above. Revocation will not apply to information already disclosed.

I understand that my records are protected under federal privacy laws and regulations under state law, and

cannot be disclosed without written consent except as otherwise specifically provided by law.

Form must be fully completed before signing.

____________________________________________________ _______________

Signature of Patient or Legal Representative (attach power of attorney) date

_____________________________________________________

Signers Name and Relationship if not patient

OFFICE OF INSURANCE REGULATION Bureau of Property & Casualty Forms and Rates

OIR-B1-1571 Pub. 1/2004

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment set forth below were actually rendered. This means that those services have already been provided.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider of the services described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

Name (PRINT or TYPE) Signature Date

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

Name (PRINT or TYPE) Signature Date

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1)(b), Florida Statutes.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

Documents

This allows our patients to achieve far ... - Chiropractorchiropalmbeach.com/wp-content/uploads/2016/08/Personal-Injury-Ne… · I give Palm Beach Chiropractic & Rehabilitation