Auto accidents form.

Auto Accident Information

After Injury

Symptoms (Check all that apply)

Work Activities Affected (Check all that apply)

Authorization & Payment Policy

I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand that the fee for service will be an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare some reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment.