Motor Vehicle Collision Questionnaire | Comprehensive Spine & Sports Center

1 Contact Information

Email *

Your name: *

Address: *

Phone number: *

Please describe the collision in your own words: *

2 Collision Details

Where did the collision occur? City/Town: *

State: *

Date of Collision: *

Time: *

Were you the: *

Driver Passenger Pedestrian

What type of vehicle were you in? *

What type was the other vehicle? *

Did your vehicle strike the other vehicle? *

Yes No

Was your car struck by the other vehicle? *

Yes No

What direction was your vehicle going? *

Was the impact from: *

The Front The Rear The Left Side The Right Side

What was the approximate speed at the time of impact? *

3 Collision Conditions

What was the weather at the time of the collision? *

Dry Wet Icy

Was your vehicle in: *

Park Neutral In Gear Moving Stopped

Were your brakes being applied? *

Yes No

Was your vehicle shoved: *

Forward Backward Sideways

Were you shoved: *

Forward Backward Sideways

4 Head Restraint & Impact Details

Did your seat have a head restraint (headrest)? *

Yes No

Did your head ride over the headrest? *

Yes No

Did your hat/glasses end up in the back seat or rear window? *

Yes No

Did any other part of your body hit the interior of the vehicle? *

Yes No

5 Body Parts Injured

6 Pre-Impact Position

Were you holding on to the steering wheel? *

Yes No

Did you brace your arms against the dash? *

Yes No

Did you brace your legs against the floorboard? *

Yes No

Was your ankle turned? *

Yes No

Did the vehicle go into a spin or roll as a result of the impact? *

Yes No

7 Damage & Immediate Aftermath

How much damage was there to the outside of the vehicle? *

None Some A lot

At the point of impact, where did you experience pain? Please be specific: *

Immediately after the accident were you: *

Conscious Dazed Unconscious

Were you wearing a seat belt? *

Yes No

8 Seatbelt & Impact Details

Did the belt have a shoulder harness? *

Yes No

At the time of impact, where you: *

Looking Straight Ahead Looking To The Right Looking To The Left Looking Down Looking Up

Did the seat break as a result of impact? *

Yes No

Were you braced for the impact? *

Yes No

Were you surprised by the impact? *

Yes No

Did you go to the hospital? *

Yes No

9 Attorney Information

Attorney Name: *

Address: *

Phone Number: *

Fax Number: *

10 Insurance Information

Insurance Company: *

Address: *

Phone: *

Fax: *

Insured Name: *

Medical Adjuster Handling Claim: *

Phone:

Fax: *

11 Patient Lien Agreement

Comprehensive Spine & Sports Center PC (CSSC) Patient Lien Agreement

By submitting this form, I hereby affirm and acknowledge my understanding and agreement to all the following stipulations regarding my treatments and responsibilities with Comprehensive Spine & Sports Center PC (CSSC).

In consideration for my (past, present, future) treatments and in forbearance of collection activity:

I understand that I am personally responsible for the payment of all charges for services provided to me by Comprehensive Spine & Sports Center PC (CSSC), that are not covered by my health or other insurance.

I grant CSSC, a lien against any judgements, settlements, or other recoveries, for any and all services provided to me by CSSC.

I further extend this lien to any settlements or litigation proceeds, including proceeds from third party actions relating to any injuries or conditions for which I am receiving treatment from CSSC, even if all or part of these services may be in theory covered by a health insurance carrier. If, at a later time, CSSC receives duplicate payment for these services, CSSC will refund the excess to me.

I understand that during the litigation and/or settlement process, my attorney may from time to time request copies of my medical and billing records. Accordingly, I authorize CSSC to disclose this information to my attorney as needed, for purposes of obtaining payment for CSSC services. I understand, however, that attorneys have the right to a fee under Miller v Citizens and that if my attorney is entitled to any fee, this will need to be arranged by a separate agreement between CSSC and my attorney.

By signing this document, I am also authorizing my attorney to release information to CSSC about the progress of my legal claims so that CSSC may be kept informed about the status of my claims in order to evaluate whether and when payment will be made for the services CSSC provided to me.

I acknowledge that I have read and agree to the CSSC Patient Lien Agreement above. *