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Auto Collision/ Personal Injury Verification
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Name
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Insured
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Policy Number
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Claim Number
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Date of Injury
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Adjuster's Name
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Has the collision been reported?
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Has a Medical File been opened?
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Benefits paid directly to doctor?
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If no, payable to patient and mail to doctor?
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Medical Insurance Information
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Insurance Company
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Policy ID
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Address
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City, St, Zip
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Phone
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Payer ID/ EDI:
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Attorney Information
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Attorney Name
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Address
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City, St, Zip
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Phone
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Accept and Honor Lien
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Fax
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Forward bills?
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Auto Insurance Information
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Insurance Company
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Policy Number
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Claim Number
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Address
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City, St, Zip
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Phone
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Fax
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About the Injury/ Collision/ Incident
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Date of Accident
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Time
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Any Passengers?
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Passengers Names
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Road Conditions at time of accident
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Did police come to the accident scene?
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Is there a police report?
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Did you request the report?
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Pain Information
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Is the patient experiencing pain as a result of the accident?
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Did you sustain any cuts or scrapes during this collision/ incident?
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Did you sustain any bruising during the collision/ incident?
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Where were you seated in the vehicle at the time of the accident?
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Where you aware of the approaching collision prior to impact?
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Where you wearing a seatbelt?
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if yes, select one
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Were you injured by the seatbelt?
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if yes, describe injury:
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Did an airbag deploy?
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Any cuts or abrasions from the airbag?
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What direction were you looking towards at the time of impact?
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Was trunk of your body facing forward at time of impact?
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if no, which direction was the trunk of your body facing?
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Did you contact the interior of the vehicle?
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What part of the body came in contact and where? (ex. head hit windshield, right knee hit dash)
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Did patient receive a head injury as result of this incident/ collision?
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Did patient experience a flash of light or explosion in your head?
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Describe any discomfort felt at time of collision? List each body part injured as a result of the collision
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Exacerbation of past injury as a result of the collision?
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If yes, Explain:
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Are there any activities that have been limited or produce pain as a result of the collision/ incident?
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Are there any movements that reproduce the symptons that were reported from the collision/ accident?
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is yes, which body part? (ex. Right wrist - bending forward/ flexion)
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Vehicle Information
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Year, Make and Model of Vehicle:
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Other Vehicles Year, Make and Model
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Was your car stopped at the time of impact?
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If yes, was the drivers foot on the brake at the time of impact?
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Where on patients vehicle did the impact occur? (ex. front driver side, rear passenger)
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What directions was the patients vehicle moving? (ex. forward, stopped, turning right)
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Was your vehicle slowing down, accelerating, or traveling at a steady rate of speed at the time of impact?
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Was the other vehicle moving at time of the collision?
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If other vehicle was moving at the time of the collision, was it: accelerating, slowing down or at a steady speed?
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What was patients speed at time of collision?
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Estimated amount of damage to patients vehicle?
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What directions was other vehicle traveling? (ex. forward, turning right)
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What was estimated speed that the other vehicle was traveling at time of the collision?
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Estimated damage of other vehicle?
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Was patients vehicle towed from the scene of collision?
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Hospital Information
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Was Emergency Medical Services at the scene of the accident?
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Was patient transported to hospital?
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If yes, What hospital?
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What treatments/ procedures were done and to what part of the body? (ex. Left hip xray?)
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Did patient stay in the hospital?
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If so, how long?
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If patient did not go to hospital, where did patient go following collision?
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How did the patient get there?
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What treatments has patient received since collision? (ex. xray, ice, heat, etc)
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Additional Information
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Where did collision occur? (cross streets, city, state)
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Please describe to the best of your knowledge, what happened during collision.
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Any pictures of the collision taken?
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Diagram of Collision
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Where was your headrest positioned? (ex. shoulder level, middle of head, top of head)
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Were both hands on the steering wheel?
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If no, which hand was on the steering wheel?
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Did anyone witness the collision?
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If yes, Who?
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Was patient transported by ambulance?
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If yes, was patient placed in a neck brace?
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Do you feel your conditions is improving, staying the same, or worsening?
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What type of work do you do?
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List job requirements:
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Can you perform physical work activities?
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Have you had a loss of income due to inability to work?
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How many days of work have you missed as a result of the collision?
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Any prior collisions?
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If yes, When?
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Any residual problems?
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If yes, Explain:
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Patient Information:
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Name
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DOB:
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Address:
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City, State, Zip
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Sex:
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If Female, could you be/ are you pregnant?
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Are you breastfeeding?
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Height:
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Weight:
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What symptoms are you currently experiencing?
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What is the intensity of your pain?
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What is the frequency of your pain?
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Which side of your body is pain located?
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What aggravates your pain?
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Is pain brought on by anything?
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Does pain interfere with your sleep?
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Any prior collisions?
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If yes, When?
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Any residuals symptoms as a result from a prior collision?
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If yes, Explain:
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What symptons do you now experience?
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Any prior surgeries?
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If yes, when/ what?
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Any current medications?
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If yes, Name & Dosage:
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Do you have drug allergies?
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If yes, please list:
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Have you had any diagnostic testing done since the collision?
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If yes, list when, where and what test was performed:
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Any questions or concerns for the doctor?
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Injuries, Impairments & Damages :
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Please mark any of the symptoms you have experienced SINCE the accident:
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Numbing/ Tingling/ Weakness in arms?
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Which Arm?
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Numbing/ Tingling/ Weakness in Legs?
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Which Leg?
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Impaired Activities:
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Select all activities that have been impaired since incident:
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Daily Activities :
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Domestic Activities:
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Household Activities:
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Work Activities:
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Hobbies/ Activities:
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Activities performed despite pain:
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Past Injuries, Collisions, or Workers Comp Claims?
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If yes, when:
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Describe your headache pain if any:
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Frequency:
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When did headaches start?
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How severe are your headaches on a scale of 1-10?
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Do any of the following worsen your headache?
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Describe your neck pain, if any:
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Frequency :
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When did the neck pain start?
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How severe is your neck pain on a scale of 1-10?
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Do any of the following worsen your neck pain?
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Describe your upper back pain, if any:
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Frequency:
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When did the upper back pain Start?
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How Severe is your upper back pain on a scale of 1-10?
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Describe your lower back pain:
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Frequency:
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When did the lower back pain start?
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How Severe if your lower back pain on a scale of 1-10?
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Do any of the following worsen your lower back pain?
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Describe your upper extremity pain, if any:
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Frequency
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When did the upper extremity pain start?
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How severe is your pain on a scale of 1-10?
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Do any of the following worsen your upper extremity pain?
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Describe your lower extremity pain, if any:
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Frequency
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When did the lower extremity pain start?
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How severe is your lower extremity pain on a scale of 1-10?
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What worsens your lower extremity pain?
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CIRCLE ALL AREAS OF PAIN
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