Accident Patient Forms

Before your first visit, please be sure to bring the following:

• Photo Identification (preferably drivers license)
• Social Security Card
• Insurance Identification Card
• Insurance Declaration page (outlining the tort threshold and type of coverage)
• Police Report
• Health Insurance (if applicable), we do not participate with any health insurance providers however if there is out of network benefits, as a courtesy to the patient we will balance bill the deductible and co-pay not covered by the motor vehicle insurance.
• If you are on medication the doctor needs to know. (list of medications)
• If you are not the insured the insurance carriers now require proof of address before the motor vehicle accident.
• Please also bring the below forms.

Below are the forms you will need to bring in:

• Patient Intake Form – English
• Patient Bill of Rights – English
• Patient Bill of Rights – Espanol
• HIPPA Privacy Statement – English
• HIPPA Privacy Statement – Espanol
• HIPPA Authorization Form – English
• HIPPA Authorization Form – Spanish
• HIPPA Acknowledgement – English
• HIPPA Acknowledgement – Espanol