Your Name*
First
Middle
Last
Suffix
Todays Date* Date of the accident?* List All Medical Providers that Treated you for this Accident Please list every doctor, hospital, clinic, ambulance driver, fireman, X-Ray, MRI, and any labs that may have done any work, or looked or treated you in any way for this accident. Please list each and every health care professional that you have seen, no matter how irrelevant it may seem to your case.
Check off every one of these that saw you for this accident: Which Fire Rescue was involved?*
Which Ambulance gave you any assistance?*
Which Hospital Emergency Department did you go to?*
Which Hospital were you admitted into?*
Which Walk In Clinics did you visit?*
What are the names of the Chiropractic offices you have been a patient in?*
Did you have any out patient X-Rays?*
Did you ever go to any place outside of the doctors office just to get X-rays? If so, tell us where you went.
Did you have any MRI's done?*
Where did you get your MRI's?
What other tests or studies were done other than X-ray or MRI? Where did you get them done?*
What other studies were done and where did you get them done?
Primary Care Physician name and location*
If you saw your Primary Care Physician, we list this doctor in your answers. Please provide the name and location of your PCP.
Neurologist name and location*
Psychiatrist name and location*
Orthopedic Surgeon name and location*
Neurosurgeon name and location*
Physical Therapy name and location*
Acupuncture name and location*
Pharmacies that I used; names and locations*
Other medical or health care providers I have seen after the collision include:*
Please help us list every medical professional you have seen. Nothing is too minor. Please tell us everything.
List EVERY health care provider you have seen in the past 10 years before this accident. This one requires you to list every health care professional you can possibly think of that you have seen in the PAST 10 YEARS. If you forget or leave out a doctor, hospital, chiropractor, walk in clinic, they will say that you were hiding this information from them and they will try to make you look like a liar. They will also suggest that your injuries you have today really came from something before this accident, not from this one. But don't worry about that because the law in Florida says that if you have pre-existing injuries or conditions and they are made worse by this crash, you are entitled to more money not less, because it is easier to hurt you, and the aggravation of pre-existing injuries will be more serious.
In the past 10 years I have seen the following:* When in doubt tell us about anything medical related, tests done, insurance examinations, anything you can think of will help us with your case.
10 years prior Primary Care Doctors information:*
Name, Address, and generally what they saw you for.
10 years prior Emergency Room visit information:*
Name, Address, and generally why they saw you.
10 years prior Physical Therapy sessions:*
Name, Address, and generally what types of physical therapy you have had.
10 years prior Chirorpractic doctors and any treatments:*
Name, Address, of any and all chiropractors you have seen for the 10 years before this accident.
10 years prior Dentists:*
Name, Address, of any and all Dentist you have seen for the 10 years before this accident.
10 years prior Hospitals:*
Name, Address, of any and all Hospitals you have seen for the 10 years before this accident.
10 years prior Walk In Clnics:*
Name, Address, of any and all Walk In Clinics you have to in the 10 years before this accident.
10 years prior Acupuncture treatments:*
Name, Address, of any and all Acupuncture treatments you have to in the 10 years before this accident.
10 years prior Psychologist visits for any reason.*
Name, Address, of any and all Psychologists visits you have to in the 10 years before this accident.
10 years prior meetings with Mental Health Care professionnals.*
Name, Address, of any and all Mental Health Care professionals you have seen in the 10 years before this accident. This includes Psychiatrists.
10 years prior meetings with any Podiatrists - foot doctor:*
Name, Address, of any and all Podiatrists you have seen in the 10 years before this accident.
10 years prior meetings with any Nutritionalist - Diet Counseling:*
Name, Address, of any and all Nutritionist(s) you have seen in the 10 years before this accident.
10 years prior pharmacies that you have used, no matter where.*
Name, Address, of any and all Pharmacies you have used in the 10 years before this accident.
10 years prior OBGYN doctors*
Name, Address, of any and all OBGYN you have used in the 10 years before this accident.
10 years any Plastic Surgeons*
Name, Address, of any and all Plastic Surgeons you have used in the 10 years before this accident.
10 years any Surgery Centers*
Name, Address, of any and all Surgery Centers, for any out patient procedures, such as colonoscopy, endoscopy, cataract surgery, etc.
10 years any Opthomologist - Eye Doctors*
Name, Address, of any and all Ophthalmologists.
10 years any Optometrists*
Name, Address, of any and all Optometrists.
10 years any other types of medical health care professionals.*
Name, Address, of any and all other health care professionals that have seen you for any reason over the 10 years before this accident.
10 years any Medical Examinations for any type of Insurance such as Life Insurance, Disability Insurance, or Health Insurance*
Name, and Reason for any Physicals you did for any sort of job, insurance, or any other reason.
Tell us the name of the insurance company who requested the exam so we can order the records.
10 years any Examinations for work or licenses you have such as a CDL or Pilots license ?*
Please tell us about any physicals or other examination you have undergone for work, or any licenses you hold. When where and why so we can order these records to help your case.
If you selected None, for no prior medical care, please explain how and why?*
If you have not seen any medical professionals for any care in the 10 years before this accident, please help us understand your explanation for this.
List any and all Pre-Existing Conditions you had before the accident that may have been aggravated in any way. The answer to this questions is usually YES! Everyone has had headaches, and colds in their life, but were you suffering from a bad back, or sore neck, or anything else before the accident occurred? Were you on medication for any condition, like high blood pressure? The fact that you have had an injury, illness or disease actually helps your case. We just have to make sure we tell them about it, so it does not look like you are trying to hide something. The law in Florida basically says that people with pre-existing conditions are entitled to more money because they are easier to hurt and harder to fix. So my suggestion is that you brag about any pre-existing injuries or conditions (no matter how old) rather than try to minimize them.
At the time of the accident did you have any medical things going on?* My prior injuries and conditions that I suffered from before this accident include:*
Please list any and all health conditions that may have been affected by this accident. Things like high blood pressure, diabetes, arthritis, rheumatoid arthritis, depression may be worsened by a accident. List them all, it is better to say too much than too little here.
The medications I was taking before this accident include:*
Please list any medications you were taking on a some what frequent basis, like baby aspirin, cholesterol medications, blood pressure medications, even daily vitamins.
I have prior injuries to my body before this accident and they were:*
List any and all injuries where you sought medical attention.
Here is a list of the surgeries I had before this accident.*
List each and every surgery you have had before this accident.
Psychologists or Mental Health Care Professionals I saw before this accident include:*
List each and every psychologist or mental health care specialist you have seen. Grief counseling, depression, job anxiety, anything. We may not need it, but let me know about this.
Describe how your pre-existing conditions have worsened by this accident.*
Please describe the additional problems you have now that were caused by the accident.
If you have never had any prior medical care or treatment before this accident, please help us understand how and why you are so fortunate.*
If you have NEVER had any treatment, be prepared to answer the question "How is it that you have never seen a doctor for anything before this accident?"
Check all injuries that you have from this accident, or were aggravated by this accident.* Please describe any other pain or injuries you attribute to this accident.
Please explain any other physical or mental symptoms or problems you relate to this crash.
Did your PIP or Health Insurance pay any bills? Did your insurance company, health insurance, medicaid, medicare, HRS, or social security pay anything for you?
Did any third party (insurance) pay any of your expenses?* If you select Yes, we will ask you who may have paid anything. Select No, if you don't have any PIP insurance, Health Insurance, Medicare, Medicaid, Social Security or any other payor.
Check all that may have paid anything My Health Insurance Company name is: My Group Number is: and my Policy Start Date was:
Please provide the Name of your Health Insurance Company, the Group number, and the date your Health Insurance Policy went into effect
The VA may have paid some bills, Tell us Which VA to order your file
Please provide the VA location where you have been treated in the past 10 years.
How do we contact Medicare? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Medicare policies, supplement policies, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
How do we contact Medicaid? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Medicaid policies, supplement policies, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
How do we contact Wellcare? Name of the carrier, group number and your policy number and the effective date your insurance started.*
Please give us the name of all Wellcare policies even if it is known by some other name, provide any supplement policies you may have, we need the name of the insurance company, the group number, your policy number and the effective date when the coverage started.
What Other types of insurance do you have that might cover payment of any medical bills, or disability?*
We need to know about any other types of insurance you might have, whether governmental paid, private insurance, things like disability insurance, AFLAC, or anything else that could potentially provide any payment for your bills or wages.
List all prior accidents of any type where you saw any type of health care provider. They just want to know what other accidents you have possibly been in where you sought ANY medical treatment, no matter how minor.
Prior accidents that I have been involved in where I had some injury include:* The insurance defense lawyer will likely have in their database a list of every time you have been to a doctor. If you can remember any prior accidents, it is going to make your case go smoother. If you forget one or two, or three accidents where you sought medical treatment, they will suggest that you are hiding these prior accidents. So, do your best to tell us and your doctors you are treating with now about any prior accidents involving ANY injury.
Describe the prior accidents. When they happened, what type of accident, Where you sought treatment and describe the injuries you received, and when your treatment stopped for those injuries.*
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