Auto Accident Intake Forms

Have you been diagnosed with:

Insurance Information:

If yes, please specify what part of your body struck what

For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column. 

For Females Only: 

Please list all Prescription Medications you are currently taking

Are you allergic to any medicines?

to

PLEASE READ BEFORE SIGNING

I understand that Family Chiropractors of Montclair is permitted by law to use my personal health information to facilitate payment of any fees and expenses. Family Chiropractors of Montclair has agreed to assist me in billing my auto insurance and any and all other applicable collateral sources. 

Although the practice will await their payment, I agree I am fully and personally responsible for all fees I incur in connection with service rendered for the purpose of today’s encounter as well as any future services.

I HAVE READ THE ABOVE INFORMATION AND CERTIFY IT TO BE TRUE AND CORRECT. I HEREBY AUTHORIZE FAMILY CHIROPRACTORS OF MONTCLAIR TO PROVIDE ME WITH CHIROPRACTIC CARE IN ACCORDANCE WITH THE STATE’S STATUES.

HIPPA FORM

We are required by State and Federal Law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.

We reserve the rights to alter or amend the terms of this privacy notice. IF changes are made to our privacy notice we will notify you, in writing, as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

if you have a complaint regarding our privacy notice, our privacy practices, or any aspect of our privacy activities, you should direct your complaint to: 

Dr. Luis Mizraji. Privacy Officer

If you would like further information about our privacy policies and practices, please contact:

Dr. Luis Mizraji. Privacy Officer

You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you lodge a complaint with this office or with the Secretary, your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective as of the date of execution listed below. This notice, and any alterations or amendments made here to will expire seven years after the date upon which the record was created. My signature acknowledges that I have read through this document and that upon my request I have received a copy of this notice for my personal records.

If you are a minor, your parent or guardian must sign or in the event of other representation issues, please have the following executed by the appropriate representing party.