Shiloh Chiropractic Motor Vehicle Accident Questionnaire printable pdf download

Shiloh Chiropractic Motor Vehicle Accident Questionnaire

SHILOH CHIROPRACTIC MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

WELCOME & INSTRUCTIONS PAGE

Please read this portion to orient you on filling this paperwork out.

Filling this out will help us speed up things for you in the office. Accident cases can be VERY complex and we find out

that both treatment AND filing is much improved when thorough note-taking is done. This form should only take about

15 minutes to fill out. These 15 minutes will save you time and money in the long run. Typically when a person is

involved in an accident, little or no out-of-pocket is required by the patient even when the patient is the “at fault” party.

But, to help achieve that goal, we need to send notifications to the right personnel.

PAGE 1: This is information about the accident. When we summarize accident details, it helps us communicate

the need for care. Filling this out accurately will help us to make sure you don’t have to worry about insurance

companies questioning or denying claims.

PAGE 2: Do not fill this page out. This is for the doctor. It is included for your benefit so you can see the types

of questions that we are going to ask you.

PAGE 3: This is required to be filled out by the second visit so that we know who to send bills to. Fill this out as

completely and accurately as possible. If something doesn’t apply, write “N/A”. If you are unsure, leave it blank

and we’ll go over it.

This form does not replace the Patient Intake Form and Pain Drawing (which still need to be filled out for each patient

being seen). No one likes paperwork but our office is thorough so that you get the care you need and the insurance

companies will not hassle you in the process! Believe it or not, our office is very effective at getting the treatment the

patient needs without too much hassle from the payers; it is this system that helps us accomplish that.

YOU MAY THROW THIS PAGE AWAY OR USE THE BACK OF IT FOR YOUR NOTES! You don’t have to bring it in.

mva_questionnaire.doc

rev 07/10

Shiloh Chiropractic Motor Vehicle Accident Questionnaire