CHARLOTTE-Salama-Chiropractic-New-Patient-AUTO-ACCIDENT-WELCOME-Form-2-27-2019

New Patient Auto Accident Welcome Form

Salama Chiropractic Center

APPOINTMENT INFORMATION

Which Salama Chiropractic Office Is Your Appointment Scheduled At?

Greensboro - 3410 West Wendover Aveue, Suite A Greensboro - 2608-A Lawndale Drive Oak Ridge - 1692 NC Highway. 68, Suite E Winston-Salem - 1515 Hanes Mall Boulevard Charlotte - 2200 Randolph Road

Appointment Date

Appointment Time

PATIENT INFORMATION

Today’s Date

Patient Full Name (First, Middle & Last Names)

Address

City

State

Zip

Email

Sex

Male Female

Age

Date Of Birth

Social Security Number

Relationship Status

Spouse’s Name

Spouse's Date Of Birth

Spouse’s Employer

Patient Occupation

Patient Employer / School

Home Phone

Cell Phone

Work Phone

Best Time & Place To Reach You

How Did You Hear About Our Office?

IN CASE OF EMERGENCY CONTACT

Name

Emergency Contact’s Phone Number

ACCIDENT INFORMATION

Is Condition Due To An Accident?

Yes No

Date

Type of Accident

Auto Work Home Other

If “Other", please describe the type of accident

Was An Accident Report Made?

Yes No

Was The Accident Your Fault?

Yes No

AUTO ACCIDENT BILLING INFORMATION

Date Of Auto Accident

City

State

Do You Have An Attorney?

Yes No

Attorney’s Name (If applicable)

What Is The Name Of The Insurance Company You Want Us To Bill For Your Treatment?

What Is The Claim Number?

Name Of Adjuster?

What Is The Adjuster’s Phone Number?

What Is The Name Of YOUR CURRENT Insurance Company?

Do You Have Medical Payment Coverage On Your Own Policy?

Yes No

OUR OFFICE POLICY

I understand that Salama Chiropractic Center is providing me valuable services in the form of Chiropractic Care without requiring payment when services are rendered. In exchange, I agree to the terms of this agreement: I agree to provide my Insurance information and/or Attorney information within 5 business days. We will send all records and bills to the Insurance company/Attorney for you. You may request a copy of your records for a charge of $15.00. Once your case has been settled and all Chiropractic bills have been paid, if an overpayment exists on your account (due to having more than one insurance) we will forward that overpayment to you. We will only reimburse you the credit that is on your account after all checks from the insurance company have cleared the bank. Please note, we are not contracted with any auto insurance company to accept reductions of your final bill as payment in full. It is your responsibility during your settlement to ensure your bill is paid at 100%. If your bill is not paid in full by your Attorney or Auto Insurance Company you will be responsible for the remaining balance on your account. By signing below I am stating that I have read the above and I understand that 100% of my bill is my responsibility if it is not paid by my Attorney/Insurance Company in full or if my claim is denied for any reason.

We DO NOT accept a statutory distribution from your Attorney as payment in full.

ASSIGNMENT OF BENEFITS

I authorize direct remittance of payment of all insurance benefits, including medical payments for all covered medical services and supplies provided to me during all courses of treatment and care provided by Salama Chiropractic Center. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated or cared for by Salama Chiropractic Center, and will constitute a continuing authorization, maintained on file with Salama Chiropractic Center, which will authorize and allow for direct payment to Salama Chiropractic Center of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by Salama Chiropractic Center. Salama Chiropractic Center may use my health care information and may disclose such information to the above-named Attorney and/or Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end three years from the date signed below.

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient