Accidents Happen, We Happen To Heal Them
First Name
Last Name
Date of Birth
Address
Phone Number
Email
Gender
MaleFemaleOther
Marital Status
SingleMarriedWidowedDivorced
Attorney Name/Group
Police Report
YesNo
Third Party Insurance Info
Emergency Contact Info
Date of Accident
General Location of Accident
To what was this injury related?
VehicleFallAnimalWorkAssault (person)Object (trauma)Other
If Other, please specify:
Were you the driver or passenger?
DriverPassenger
If needed, additional details:
Were you wearing your seatbelt?
Did any of the airbags deploy?
Did you have a head injury?
Did you lose consciousness?
Where was the vehicle contacted?
Front endRear endDriver's sidePassenger's side
What body parts are you experiencing pain?
Rate your pain on a scale of 0-10 (0 = no pain, 10 = severe pain)
Pain is described as (select all that apply):
Sharp or stabbingDull or achingConstantIntermittent (comes and goes)WeaknessNumbness, tingling, or burningStiffness, tightness, cramps, or spasmsSwelling or bruisingBleeding or wounds
What improves the pain?
What worsens the pain?
Pain impairs the ability to perform (select all that apply):
Household choresExerciseDrivingFamily CareWorkingNone
Negative emotional impact causing problems with (select all that apply):
Depression or anxietyLack of sleepMemory problems or forgetfulnessOtherNone
List any diagnostic imaging completed after the incident (select all that apply):
MRIXrayCT ScanNoneOther
List the body part and facility name where imaging was completed:
List any care or management received after the incident (select all that apply):
Hospital (emergency department)ChiropractorPhysical TherapyPrimary CareUrgent CarePain ClinicSurgeonOtherNone
Medical History (select all that apply):
Hypertension (high blood pressure)DiabetesMyocardial infarctionPacemaker/defibrillatorCongestive Heart FailureChronic Kidney DiseaseStroke(s)Chronic MigrainesEpilepsy (seizures)Hepatitis or HIVCancerDeep Vein Thrombosis/Pulmonary EmbolismOtherNone
If Cancer or Other, please specify:
Surgical History (include body part and approximate year)
Family History (maternal)
Family History (paternal)
Social History (select all that apply):
AlcoholTobaccoIllicit drugsNone
If illicit drug use, please specify:
Allergies to Medications
If Yes, please specify medication and reaction:
Please list any current medications
Preferred Pharmacy
Pharmacy Address
I request that payment insurance benefits be made to either me or on my behalf to Sol Medical for any services furnished to me by the Physician/Provider. I authorize any holder of medical information concerning me to be released to my insurance carrier or Health Care Financing, its agents; any information needed to determine these benefits or the benefits payable for related services. A photocopy of this authorization shall be considered effective and valid as the original.
I understand that I am financially responsible for all charges not covered by my insurance company.
Notice of Privacy:
To Our Patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by HIPAA.
Our commitment to your privacy:
• Our practice is dedicated to maintaining the privacy of your health information.
• We are required by law to maintain the confidentiality of your health information.
Use and disclosure of your health information in certain special circumstances:
1. To public health authorities and health oversight agencies authorized by law.
2. In lawsuits and similar proceedings in response to a court or administrative order.
3. If required by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or that of others.
Your rights regarding your health information:
1. You can request specific communication methods or locations.
2. You have the right to request restrictions on disclosure.
3. You have the right to inspect and obtain a copy of your health records.
4. You may ask to amend your health information if inaccurate.
5. You are entitled to a copy of this Notice of Privacy Practices.
Assignment, Lien, Authorization, and Power of Attorney:
I hereby authorize and direct any insurance company and/or my attorney to pay directly Sol Medical any sums due for services rendered, whether for accident or illness treatment, and grant Sol Medical a lien against any insurance benefits I may be entitled to. I assign all my rights to any applicable PIP benefits, including the right to file suit or seek arbitration.
I acknowledge that I remain personally responsible for the total amounts due, and that this assignment and authorization do not require waiting for insurance payments. I agree to endorse any insurance check over to Sol Medical within 30 days.
Sol Medical 3118 W. THOMAS RD., STE 711 PHOENIX, AZ 85017 PHONE: (602) 456-2821 FAX: (602) 584-4924
Patient Name
To/From (Who is requesting/receiving records)
By signing below, I authorize the release of Medical Records and Imaging Reports.
Authorization Terms
I may revoke this authorization except to the extent that it has already been acted upon.
Treatment may not be conditioned on my providing this authorization unless it is solely for creating protected health information for disclosure to a third party.
Once this information is released, it may be re-disclosed by the recipient and may no longer be protected.
Unless otherwise revoked, this authorization will expire five (5) years from the date of my signature.
I am entitled to a signed copy of this authorization.
I accept the above terms for the release of my protected health information.
Signature (type your full name as signature)
Date of Signature
I understand:
1. I may revoke this authorization except to the extent it has been acted upon.
2. Treatment may not be conditioned on this authorization unless solely for creating protected health information for third-party disclosure.
3. Once information is released, it may be re-disclosed and may no longer be protected.
4. This authorization will expire five (5) years from the date of my signature.
5. I am entitled to a signed copy of this authorization.
Please sign below with your mouse or finger (required):
Clear
Δ
