Patient Questionnaire Form

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Patient Name: ___________________________________________
Treatment for Injury: ______________________________________
Member number (see back of your HMO card): _________________
YES
NO
1. Did you have an injury around the period indicated in our cover letter?
If your answer is "NO" to this question, you do not need to return this survey.
If YES, were you injured:
a. in an auto accident?
b. on someone else’s property?
c. by the negligent act of a third person?
2. Have you or do you intend to bring an injury claim against the person(s) who caused your
injuries?
If your answer is "NO" to this question, you do not need to return this survey.
If you answered Yes to any of the above questions, please complete the following. If NO, skip to question #3.
a. Date of injury: ________________________________________________________________
b. Responsible insurance company (auto/home): _______________________________________
c. The claim/policy number is: ______________________________________________________
d. The name and telephone number of the adjuster is: ___________________________________
e. My attorney's name and telephone number is: _______________________________________
f. My auto insurance company is: ___________________________________________________
g. Do you have a medical payments provision in your auto policy? (yes/no) __________________
3. Were you hurt at work? (yes/no) _____________________________________________________
If you answered Yes to #3, please complete the following. If NO, please sign below and return.
a. Date of injury: ________________________________________________________________
b. My social security number is: _____________________________________________________
c. My employer is: _______________________________________________________________
Contact in Human Resources and Phone #: _________________________________________
d. My employer’s Worker’s Compensation insurer is: ____________________________________
Adjuster’s Name and Phone Number: _____________________________________________
Claim Number: _______________________________________________________________
e. My attorney's name and telephone number is: _______________________________________
4. If you answered yes to any of the above questions, please list the name, address and phone numbers of all
of your treating physicians and physical therapists for this incident. If none, please send in the completed
form in the enclosed envelope. If you require more room, please use the back of this form.
1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
If we have any questions, who may we call? Name: ____________________________
Phone: ____________________________ Best Time to Call? (please circle):
Day
Evening
Thank you for your cooperation. Please return the completed questionnaire in the enclosed envelope to:
Hill Physicians Medical Group
PO Box 5080
San Ramon, CA 94583-0980
Attn: TPL
T (800) 445-5747 / (925) 820-8300
F (925) 820-2335

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