RELEASE OF AUTHORIZATION AND LETTER OF PROTECTION

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Magdalen Sherman
5 years ago
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1 RELEASE OF AUTHORIZATION AND LETTER OF PROTECTION I,, hereby authorize this office to furnish my attorney,, and/or Insurance Company, or the designee of either, any medical information requested concerning the condition or treatment of injuries sustained by me and/or my children, on. I authorize and direct my attorney to pay from any insurance or other proceeds for any recovery made as a result of said injury; any unpaid balance due said doctor for professional services as a result of any treatment to myself, or my children. I understand that this in no way relieves me of my personal primary responsibility to pay my doctor for service when a statement is rendered and that I will receive customary billing for said services. I authorize my attorney or any third party liability carrier to disclose the settlement status, settlement statement and/or a copy of the settlement check if requested for our purposes. At the time of the settlement, the attorney is instructed that this office shall be furnished separate checks for the medical services which they have rendered for full balance due at that time. Upon settlement of the underlying, the attorney s office will disburse funds directly to Dr. Nailah Smith. The patient hereby acknowledges that should the net recovery to the patient not be sufficient to pay in full all amounts due this office with respect to the above stated matter, then the patient shall remain personally responsible for any unpaid balance. 1. I understand that I am being treated for personal injury case and that failure to keep my appointments may jeopardize the insurance carrier s responsibility for medical costs and/or compensation for pain and suffering. 2. I understand that this office is extending me credit for treatment and that if I miss two (2) office visits without a reasonable excuse all bills may be due immediately. 3. I understand that if I sever ties with my attorney before settlement or my attorney will no longer represent my case, all bills may be due immediately. 4. Once released from care, if my case is not settled within six months I will begin making payments of $25.00 a month to this office toward my bill. 5. If my bill is not paid within 10 days after the settlement, my balance will then be doubled. 6. I further understand that if my account is placed in collection status for non-payment or forwarded to a collection agency that I will be assessed a fee of 33% of my current balance. PATIENTS SIGNATURE DATE SOCIAL SECURITY # FULL BODY REJUVENATION CENTER 3636 Panola Rd. Suite B Lithonia, GA

2 ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE I hereby instruct and direct the Insurance Company/ Attorney to pay by the check made out and mailed directly to: Full Body Rejuvenation Center 3636 Panola Rd. Suite B Lithonia, GA If my current policy prohibits direct payment to the doctor, then I hereby also instruct and Direct you to make out the check to me and mail it as follows: See Above Address For the professional or chiropractic expense benefits allowable and otherwise payable to Me under my current insurance policy as payment toward the total charges for Professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned Assignee, and I have agreed to pay, in a current manner, any balance of said professional Service charges over and above this insurance payment. A photo copy of this Assignment shall be considered as effective and valid as the Original. I also authorize the release of any information of pertaining to my case to any insurance Company, adjuster, or attorney involved in this case. Dated at this day of 20. Signature of policyholder Signature of Claimant, if other than Policyholder

3 ATTORNEY NOTIFICATION Date: Patient s Name: DOB: SS#: Address: Home Phone#: Cell Number#: Date of accident: Name of Attorney: Phone Number: Address: Fax Number: I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me by Dr. Nailah Smith, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies. I authorize my attorney,, to distribute to Dr. Nailah Smith payment for all medical services prior to distribution of my settlement to me. I further understand that if my case does not settle in days that I will be obligated to make monthly payments of $ to Dr. Smith until my balance is paid in full or my case is settled. I understand that I will be assessed a fee of 33% of my current balance should my account be forwarded to a collection agency. Signature of Patient: Signature of Doctor: Signature of Attorney:

4 Date: PERSONAL INJURY VERIFICATION Patient s Name: DOB: SS#: Address: Home Phone#: Date of injury: Who was at fault: Type of Injuries: Was injury reported? Yes NO Who was injury reported to? Have you been treated for this injury by someone else? Yes/ No If so, whom? Name of Insurance Carrier: Phone Number: Address: Name of Adjuster: Claim Number: Do you have Med Pay on your policy? Is there an attorney involved? Yes / No If so, name of Attorney: Address: Phone Number: I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me by Dr. Nailah Smith, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies. I authorize my insurance carrier, to provide Dr. Smith s office the information listed below for billing my Injury Medical Claim. I further understand that if my account becomes delinquent that I will be assessed a 33% of my balance as a delinquent fee. Signature: Carrier Authorization Name of Person Giving Authorization: Title: Claim Number: Adjustor s Name: Bills are to be submitted to: Name: Phone Number: Address: Fax Number: Number of visits authorized? Will this include physical therapy (modalities)? Yes No Will we need to call before/after each visit? Any Special Billing Instructions: Signature: Date:

PHYSICAL THERAPY & CHIROPRACTIC CARE

PHYSICAL THERAPY & CHIROPRACTIC CARE Patient Information Name: Social Security #: Date of Birth: Telephone: Home: _ Cell: Email: (Communications are for appointments, office information & newsletters)