ACCIDENTS HAPPEN ARE YOU ABLE TO BILL MEDICAL FOR THEM?

This outline will help you document all you need. When you are ready to bill then you can use this guide to help direct you to the codes needed.

ACCIDENT REPORT  

PATIENT NAME_____________________________  TODAY’S DATE___________

DATE OF ACCIDENT ____________  TIME OF ACCIDENT__________________

PLACE OF ACCIDENT __________________________________________________

TYPE OF ACCIDENT:                                                                              

Auto:    Driver ___  Passenger ___  Type of Vehicle ____________________

 Activity of patient at time of accident______________________________                       

Fall:     From one level to another, falling down a level, or same level You must document if they slipped, tripped, fell, plus the following

Hit by blunt force:  Fight, brawl, or beaten __

Sports Injury

Work Related

Intentional _______ or Accidental ______

Where did it happen?_________

HAVE YOU SOUGHT OTHER MEDICAL SERVICES RELATED TO THIS ACCIDENT?  ÿ Yes   ÿ No 

Name of:    Physician _____________________________  Phone # ________________

                  Dentist ________________________________ Phone #________________

                  Hospital _______________________________________________________

IS THERE A POLICE REPORT OR EMERGENCY ROOM REPORT:      YES  NO

DESCRIBE THE ACCIDENT IN DETAIL: ____________________________________

SYPMTOMS AND PAIN

What parts of the body were injured? ________________________________________________________________________

Describe the pain and its location at the time of the accident ____________________ ________________________________________________________________________

Describe current pain and symptoms ________________________________________

Have patient sign, and witness in office sign that the patient gave this information to you with full knowledge that billing for any services without any paperwork to back up is not possible without the ability to add they gave this to you, and you are sending it in for patient.

Signature of Patient ___________________Date_________________

Signature of Witness __________________Date _________________

Signature of Provider _________________Date________________