630-236-8600 / 630-708-2225

Personal Injury

Paperwork must be completed prior to your visit so we can spend your scheduled appointment time completing your exam and answering any questions/concerns you may have. If you do not have access to a printer, please arrive 15 minutes prior to your appointment to complete these forms at our office. We look forward to meeting you!

Please click DOWNLOAD to complete your personal injury paperwork. Feel free to contact us if you have any questions.

Complete the pdf forms and save the file on your computer. Print all forms and sign where applicable. Bring your completed forms with you to your scheduled appointment along with your insurance information.

 
  • Personal Injury
  • Intake
  • Consent to Treat
  • Hippa
  • Benefits
  • Office Policy

Initial Report of Injury

 
Mark with an "X" to describe your current experience with the following activities:
ACIVITY NORMAL LIMITED DIFFICULT PAINFUL
Walking
Standing
Sitting
Bending
Lifting
Reaching
Pushing/Pulling
Using Stairs
Getting up from a chair
Gripping
Desk Work
Sleeping
 

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Chiropractic Registration and History

Patient Information
Male   Female
Single   Married   Widowed   Separated   Divorced
Insurance and Financing

Is patient covered by additional insurance?

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Spinal Rehab & Wellness Center and/or Specialists all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance company. In the event the payment is not made and this account is referred for collection, I will pay the cost of collection. If suit or action by an attorney is instituted, I will pay reasonable attorney fees in said suit or action. Invoice payments will be due upon receipt and are considered past due thirty (30) days from date of invoice, including acceptable lien cases. Interest at the rate of 1.5% monthly will apply to past due amounts. Additionally, I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions and acknowledge receipt of Privacy Notice given to me (Federal HIPPA Privacy Practices).

Phone Numbers
IN CASE OF EMERGENCY CONTACT
Accident Information
Yes   No
Auto   Work   Home   Other
Patient Condition
Yes   No   Unknown

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Type of pain
Sharp
Dull
Throbbing
Numbness
Aching
Shooting
Burning
Tingling
Cramps
Stiffness
Swelling
Work   Sleep   Daily Routine   Recreation
Sitting   Standing   Walking   Bending   Lying Down
Health History
Medications   Surgery   Physical Therapy   Chiropractic Services   None
Name and address of other doctor(s) who have treated you for your condition
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
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Yes   No
Yes   No
Yes   No
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Yes   No
Yes   No
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Yes   No
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Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Yes   No
Exercise
None   Moderate   Daily   Heavy
Work Activity
Sitting   Standing   Light Labor   Heavy Labor
Habits
Smoking   Packs / Day
Alcohol   Drinks / Week
Coffee/Caffeine Drinks   Cups / Day
High Stress Level

Yes   No
Injuries / Surgeries History
Medications, Allergies, Supplements
Medications Allergies Vitamins / Herbs / Minerals
Pain Drawing

Key

Mark an X on the picture where you continue to have pain, numbness, or tingling

Use Letters below to indicate type and location of Discomfort
A = Ache B = Burning
C = Stabbing N = Numbing
P = Pins & Needles O = Other
pain drawing
 
  
 

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Consent to Examine / Treat / Insurance Authorization

I, , give consent to be examined and treated by the team of specialists at Spinal Rehab and Wellness Center. I have been informed of the examination findings and proposed treatment plan and give himrisks and benefits of chiropractic care and allow treatment. I give authorization of SRWC to contact my insurance company for treatment received at SRWC. Insurance information provided by the patient is solely used for the purpose of repayment of treatment being rendered. I understand that my insurance may not cover the cost of treatment fully. I am liable for treatment costs not covered by my insurance company (co-pays, deductible, other services not covered by insurance). All information provided by the patient is confidential and will not be misused. SRWC is HIPAA compliant and abides by its regulations.

We would like to keep you updated on the progress of your treatment along with sending you tailored exercise and stretches for your treatment. Your email address is solely confidential to Spinal Rehab and Wellness Center.

 
  
 

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Consent for Use or Disclosure of Health Information

Spinal Rehab and Wellness Center has always been concerned with protecting our patients' privacy. While the law requires us to give you the HIPAA disclosure, please understand that SRWC has and always will, respect the privacy of your health information.

There are several circumstances in which we may have to use or disclose your health care information.

We have a more complete notice that provides detailed descriptions of how your health information may be used or disclosed. We reserve the right to change our privacy policy as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come into the office for treatment or by mail. Please feel free to call us at any time for a copy of our privacy policy notices.

Your right to limit uses or disclosures

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing.

Your right to revoke your authorization

You have the right to revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I have read your consent policy and agree to its terms. I am also acknowledging that I have a right to receive a copy of this notice.

Effective Date: April 14, 2003

Address:
Spinal Rehab and Wellness Center 3450 Montgomery Road Suite 21, Aurora, IL 60504

 
  
 

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Assignment of Benefits

I request that payment of authorized insurance benefits, including Medicare if I am a Medicare Beneficiary, be made either to me or on my behalf to the organization listed below for any equipment or services provided to me by that organization.

I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my Insurance Carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my Insurance Company or other entity, if requested. The original authorization will be kept on file by the organization.

I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received.

General Patient and Patient Family Responsibilities:

In certain circumstances, insurance company may send a check for services provided by Spinal Rehab & Wellness Center directly to the patient. In such cases, the patient agrees to endorse and send such a check to Spinal Rehab & Wellness Center. If the patient deposits such a check into a personal account, the patient agrees to send Spinal Rehab & Wellness Center a check for the equivalent amount.

If the patient receives from an insurance company an Explanation of Benefits (EOB), the patient agrees to send a copy of the EOB, by mail, or fax.

 
  
 

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Office Policies

In order to better serve our patients, we have established these office policies. Please let us know if you have questions on any of our current policies.

Late Appointments: If a patient is greater than 10 minutes late we will do our best to accommodate them into our schedule. There may be a long wait as our patients who do arrive at their scheduled time will be seen first. If a patient is more than 20 minutes late, we kindly ask you to reschedule.

Missed Appointments: Failure to show-up for appointments could result in a $50.00 fee.

Cancelled Appointments: We realize that sometimes cancellations cannot be helped, but we kindly ask for a 24 hour notice of any cancellations.

Co-Pays: Co-pays are due at the time of service.

Past Due Balances: Past due balances are due at the time of check-out.

Insurance:

If you have health insurance, we bill it as a courtesy for you. If you have a co-pay it is your responsibility to pay at the time of service.

If you have a health insurance and are unable to provide us with a card, we are unable to bill your insurance. We will require you to pay in full at the time of service.

If you do not have health insurance, we require you to pay in full at time of service. If you are unable to pay for the day's charges in full, we kindly ask you to reschedule your appointment or work out a payment plan. All outstanding balances (greater then 60 days) will be turned into collections. If your account ends up in collections all reasonable attorney's fees, and/or court costs incurred by SRWC to enforce terms, covenants, or defend upon the same and/or to collect any balances owed past sixty (60) days shall be awarded to SRWC by any court of competent jurisdiction.

For your convenience we except cash, personal check, Visa, CareCredit, MasterCard and Discover.

 

 
 
  
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