QL MVA Paperwork

Name*
First Last
Email*
Enter Email Confirm Email
Date*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mobile*
Cell Carrier:
Home Phone
Date of Birth*
Sex*
- Male
- Female
Social Security Number
Status
- Married
- Single
- Widowed
- Divorced
Name of Spouse:
First Last
Patient's Employer Name
First Last
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employer Phone Number
Job Description
Health Insurance
- Yes
- No
Insurance Carrier Name
Insurance I.D. Number:
Group Number
Reason For Today’s Visit:*

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MVA Only :
Date of Collision
Location of Collision
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Describe Accident
Type of accident
- Rear End Collision
- Head On Collision
- Broadside Collision
- Pedestrian
- Other
Where were you located?
- Driver
- Passenger Front seat
- Passenger Rear seat Left
- Passenger Rear seat Right
- Walking
- Riding a bike
- Riding a Motorcycle/Scooter
If “driver”, were your hands on the wheel?
- Both
- Right
- Left
Did Air bags deploy?
- Yes
- No
Did you strike another vehicle?
- Yes
- No
Did another vehicle strike your vehicle?
- Yes
- No
Was your headrest set
- Low
- Mid
- High
Were you surprised by the impact?
- Yes
- No
If no, how did you brace?
- With hands
- with feet
Which direction was your head facing at time of impact?
- Straight
- Left
- Right
- Behind
Was your vehicle drivable after the collision?
- Yes
- No
Was your vehicle towed?
- Yes
- No
What type of vehicle were you driving?
Make Model Year
What was your approximate speed at the time of impact?
What type of Vehicle was the other Vehicle?
Make Model Year
What was the approximate speed of the other vehicle at the time of impact?
Did you feel pain immediately after the collision?
- Yes
- No
Did you black out at the time of the impact?
- Yes
- No
- Unknown
Did you strike anything in the vehicle at the time of impact?
- Yes
- No
If yes, what body part did you strike and describe you struck it on?
Were the police at the scene of the collision?
- Yes
- No
Did any one receive a ticket?
- Yes
- No
Were you injured as a result of the collision?
- Yes
- No
Check what part of your body was injured:
- Head
- Face
- Jaw
- Neck
- Middle Back
- Low Back
- Chest
- Left Side Ribs
- Right Side Ribs
- Left Arm
- Right Arm
- Left Elbow
- Right Elbow
- Left Wrist
- Right Wrist
- Left Hand
- Right Hand
- Left Hip
- Right Hip
- Left Knee
- Right Knee
- Left Ankle
- Right Ankle
- Left Foot
- Right Foot
- Other

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Worker’s Comp Only:
Where you injured while at work?
- Yes
- No
Date of Injury:
Name
First Last
Signature
Date
Slip and Fall Only:
Where you injured due to a slip and fall?
- Yes
- No
Date of slip and fall
Name
First Last
Signature
Date

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1. Reason for seeking chiropractic care:
Have you ever received Chiropractic Care?
- Yes
- No
If yes, when?
Reason For Today’s Visit:
Previous treatments, medications, surgery, or care you’ve sought for your complaint(s):

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Pain and Symptoms
1. Pain Area:*
Pain Level*
- 1 - No Pain
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Worst Pain
2. Pain Area:
Pain Level
- 1 - No Pain
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Worst Pain
3. Pain Area:
Pain Level
- 1 - No Pain
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Worst Pain
4. Pain Area:
Pain Level
- 1 - No Pain
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Worst Pain
5. Pain Area:
Pain Level
- 1 - No Pain
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 - Worst Pain
Please check off the areas you are having pain below
Body Pain Areas*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
Select the checkbox that corresponds to Body Points above
What activities of daily living cause you to have increased pain: List them here:
Which of the following cause you to have increased pain:
- Sitting
- Standing
- Walking
- Twisting
- Bending
- Lifting
- While in bed
- Climbing
- Stairs
- Turning
- Turning in Bed
- Up from Sitting
- Bowel Movement
- Urinating
- Sexual
- Activity
- Other
Describe any other movements that cause increased pain
Were you ever injured in a motor vehicle collision before?
- Yes
- No
If yes, when
What parts of your body was injured in that collision?

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Patient Name
First Last
HIPAA NOTICE OF PRIVACY PRACTICES
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 describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law.
“Protected Health Information” is information about you, including demographic information that may identify you
and that related to your past, present, or future physical or mental health or condition and related care services.
Use and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, pay your health care bills, to support the operations 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 services. 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, your health care 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 your 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 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, employee review activities, training of medical students, licensing, marketing, and fund raising activities, and conduction 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 use 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, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation. Required uses and disclosures under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section164.500. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW.
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.
- By clicking this box, I (signer) am verifying that i have received the HIPAA NOTICE OF PRIVACY PRACTICES
Signature
Name
First Last
Date

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INFORMED CONSENT TO CHIROPRACTIC TREATMENT*
I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my
circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

SIGN ONLY AFTER YOU UNDERSTAND AND AGREE TO THE ABOVE
- By Clicking this box, I (the signer) am verifying that I received the informed consent to chiropractic treatment
You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3- 4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.
Patient Name
First Last
Signature of Patient
Date
Signature of Representative (if patient is minor or handicapped)
Date
Witness to Patients’ Signature
Date

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HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
TO: QUALITY LIFE HEALTH CARE LLC. 46 Prince Street Suite 201 New Haven, CT 06473
RE: Patient Name:
First Last
Date of birth
Social Security
I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:
- All medical records
- All physical, occupational and rehab requests, consultations and progress notes.
- All disability, Medicaid or Medicare records including claim forms and record of denial of benefits.
- All employment, personnel or wage records.
- All radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myelogram; nerve
- conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels, and reports
- All pharmacy/prescription records including NDC numbers and drug information
- All billing records for the period
From
To
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is disclosed for the following purposes:
This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been specifically considered and expressly waived. You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:
Name
First Last
Signature
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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NOTICE OF DOCTOR’S LIEN

I do hereby authorize Quality Life Health Care, LLC to furnish you, my attorney, with a full report of my examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved. I hereby authorize and direct you, my attorney, to pay directly to said provider such sums as may be due and owing him for medical service rendered to me both by reason of this accident and by reason of any other bills that are due to this office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said provider. I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection there with. I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him. I fully understand that I am directly and fully responsible to said provider for all medical bills submitted for service rendered to me and that this agreement is made solely for said provider's additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. Please acknowledge this letter by signing below and returning to the provider’s office. I have been advised that if my attorney does not wish to cooperate in protecting the provider's interest, the provider will not await payment but shall declare the entire balance due and payable.
Patient's Signature*
The undersigned being the attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect said provider above named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs.
Attorney’s Signature
Date
Comments
This field is for validation purposes and should be left unchanged.

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Injury Paperwork

MVA Only :

Worker’s Comp Only:

Slip and Fall Only:

1. Reason for seeking chiropractic care:

2. Hospital

Pain and Symptoms

Please check off the areas you are having pain below

3. Past Medical History

4. Family Health History

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508

NOTICE OF DOCTOR’S LIEN

We treat these and other conditions:

Cervical pain:

Shoulder Pain:

Thoracic Spine:

Knee Pain:

Lumbar Spine:

Foot/Ankle Pain:

Elbow Pain:

Wrist Pain:

Hip Pain:

Lower Extremity:

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Patient Documents

QL Illness Paperwork

QL MVA Paperwork

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