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8 Graddy Chiropractic 4625 S. Harvard Ste. 200 Tulsa, Ok p f. PLEASE READ AND INITIAL EACH STATEMENT 1. AUTHORIZATION FOR CARE AND TREATMENT: I request and consent to the rendering of health care services, which may include but not be limited to diagnosis and treatment services by the Doctors and the staff at Graddy Chiropractic. 2. FINANCIAL AGREEMENT: I agree to pay all fees charged by Graddy Chiropractic and its associates for the health care services from my health care plan or any other third-party. I understand that, although Graddy Chiropractic may submit a payment request to my health plan or another third-party, I will be responsible for payment of all charges. I also understand that I will be required to make any co-payments or co-insurance payments established by my health plan at the time service is provided. I agree to pay interest at the rate of 1.5% per month on any charges which are not paid on my account within 45 days of the date of billing. I further agree to pay a RETURNED CHECK CHARGE OF $25.00 PLUS ANY BANK CHARGES per check for any check that is returned unpaid by my bank for any reason. 3. AUTHORIZATION FOR DIRECT PAYMENT AND ASSIGNMENT OF CLAIM: I, the undersigned patient in consideration of services rendered, herby assign and transfer access to all health benefits as it pertains to my treatment and payments for such services, to Graddy Chiropractic, Dr. Christina Graddy. A copy of this assignment shall be valid and effective as if it were the original. 4. CANCELLATION/ NO SHOW APPOINTMENT: We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment due to a seemingly "full" appointment book. if an appointment is not cancelled at least 24 hours in advance you will be charged a $25 fee this will not be covered by your insurance company. S. RELEASE OF INFORMATION TO THIRD PARTY INSURANCE AND ANY REFERRALS MADE ON BEHALF OF TREATMENT: authorize Graddy Chiropractic and Its associates to release information from my health records to any health care provider involved in my care and to my health plan or to any third-party payer which is or may be liable for all or part of the charges of Graddy Chiropractic and its associates. I ACKNOWLEDGE THAT I HAVE READ THIS FORM AND AGREE TO ITS CONTENTS, I FUTHER ACKNOWLEDGE THAT I AM THE PATIENT IDENTIFIED ABOVE OR THAT I AM AUTHORIZED BY LAW TO CONSENT TO TREATMENT OF THE PATIENT. Signature of patient or authorized representative: Date: Witness: If signed by Authorized Representative: Print name: Authorization:

9 Assignment of Benefits and Financial Agreement I understand that Central Plains Radiologic Services, P.A. (hereinafter referred to as CPRS) is an outside radiology practice and that my doctor uses their services for radiologic consultation services and will/may send my x-rays or other diagnostic imaging procedures to CPRS for professional consultation. I understand and agree that unless the doctors of CPRS have a separate agreement with my insurance company, my health insurance policy is an agreement between my insurance carrier and myself. I understand that as a service to their patients, CPRS will prepare reasonably necessary reports and forms to assist me in making collection from my insurance company. I hereby authorize CPRS to release any information deemed necessary and appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement, for coverage eligibility, and to representatives of any liability claims. I understand that if my insurance company requires a primary care physician referral for benefit eligibility that it is ultimately my responsibility to obtain that authorization, and agree to be responsible for all services rendered now and in the foture, in the event of a denial. I also agree to be responsible for payment of services ir. the event ofa denial from my carrier for any reason regardless of CPRS contract status with my carrier. I authorize direct payment to CPRS for any sum I now, or hereafter owed to CPRS by any insurance company or attorney out of the proceeds of any -;ettlement of my case. In the event the insurance plan prohibits payment to a non-participating provider, I hereby direct the ;-Jhn to make any draft of payment payable to me be sent to P.O. BOX 190 Cheney, KS This direction is irrevocable.: hereby autho1ize CPRS to endorse a1.1y such check or draft on my behalf, and retain those proceeds and apply them tovv::.rds the balance of my account I understand that I am ultimately responsible for payment in full to CPRS for any fees for pro,:~s~l')!!al ser1ices, and the costs incurred (court costs, filing fees, statements, late fees, etc.) in collecting my debt. By sigr~eg 1 ::,e:ow ;_ a:rn veri!~ring th2t I have read and agree with the above assignment and agreement. If the patient is a minor child, 111,v ~ignatun: he"'e a'so authorizes the evaluation and current/ future treatment ofmy child by any CPRS staff. Medicare p21tie1:ts: Medkare does ;:mt cover this services and I agree to be responsible for the charges and pay the charges directly t(l '::']E Rf,. Educational materials: By signing below I give permission to Dr. Gould to use my images and case history (without patient identification) for the purposes of education in post-doctorate lectures, presentations and written articles for publicarion. Permission may be withdrawn by separate signature here Patient/ Guardian Signature Date_/_/_ Medical Lien: In the case of (patient) who is represented by attorney at law, wherein (patient) has incurred medical expenses with Central Plains Radiologic Services in the amount of$. I ensure that said medical provider will be paid from any insurance proceeds or other recovery through litigation or settlement. Central Plains Radiologic Services agrees to withhold further billings and collection activity toward (patient) until the time that settlement is finalized. Signed: (insured the/authorized person) Date Signed attorney at law. Date Notice of Receipt of Privacy Notice of Central Plains Radiologic Services, P.A. (CPRS) and Cheney Health Center/Gould Chiropractic. CPRS may use electronic transmission of images or patient information for purposes ofrendering treatment, professional opinion and for payment by third party payers. By signing below, I acknowledge that I have received and reviewed the Privacy not:;:;e e,f CPRS, m force as of April 14, 2003 and all of my questions have been answered to my satisfaction in language that I can underst<i,1d. Name of Individual (Printed) Signature of individual Signature of Legal Representative Relationship(e.g., Attorney-In-Fact, guardian, Parent ifa minor): Date Signed / / Witness: Central Plains Radiologic Services, P.A. 126 N. Main Cheney, KS

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