Initial Treatment Plan (Chiropractic Care-Massage Therapy-Other)

Print Form IDAHO CRIME VICTIMS COMPENSATION PROGRAM Initial Treatment Plan CHIROPRACTIC CARE CV#: Parent/Guardian: Treatment Provider Facility Name: Credentials: Are you a provider under the following programs? Medicaid Medicare Blue Cross Indian Health Services MASSAGE THERAPY Patient's Name: Tax I.D. #: PHYSICAL THERAPY TriCare Blue Shield Other Indicate what sources of payment are available to this patient: Date treatment began: Number of sessions to date: 1. Please describe the presenting symptoms or conditions for which the patient is seeking treatment. 2. Does the patient have a history of any conditions that required similar treatment in the past? Yes No If so, please indicate the type of treatment, approximate dates and reasons for treatment. 3. Please provide a brief description of the crime as related to you, including a description of the injury sustained and the source of the information (i.e. patient, parent or other). 4. Please describe any pre-existing conditions that may affect treatment and to what extent these conditions may have been exacerbated by the crime. 5. Indicate percentage of treatment you are providing that resulted from pre-existing or non-crime related injuries. % C:\formdocuments\Initial Treatment Plan ­ Chiro PT Massage (1/05) American LegalNet, Inc. www.FormsWorkFlow.com 6. Describe the symptoms or conditions you are treating that are a direct result of the crime. 7. Indicate percentage of treatment you are providing for conditions that are a direct result of the crime. % (Percentages from #5 and #7 should equal 100%) 8. Estimated duration of treatment: 9. Estimated cumulative cost of treatment: from $ to 10. List below the treatment goals for this patient, give specific physical measures and projected dates to achieve each goal. Symptom/Condition Treatment Goal Method Target Date 14. I certify that the information provided in this treatment plan is true and accurate. I acknowledge that if the alleged offender is convicted, the Program will request the criminal court to order the alleged offender to pay restitution to reimburse the Program for expenses paid on behalf of the patient. I further understand that this document may be submitted as evidence and that I may be called to testify regarding the treatment outlined in this plan. Signature of Treatment Provider Title Date C:\formdocuments\Initial Treatment Plan ­ Chiro PT Massage (1/05) American LegalNet, Inc. www.FormsWorkFlow.com