DOCTOR'S LIEN. (Patient Signature)

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Emery Paul
5 years ago
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1 DOCTOR'S LIEN TO: _ RE: =~--~~~ (Patient's Name) I hereby authorize Dr. L. Lee Smith to furnish my attorney and/or insurance company with a full report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was involved. I hereby authorize and direct my attorney and/or insurance company to pay directly to Dr. L. Lee Smith such sums as may be due and owing him for his professional services rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict as may be necessary adequately to protect said doctor. I hereby further give a lien on my case to said doctor against any and all proceeds of any settlement, judgment or verdict which may be paid to my attorney and/or myself as the result ofthe injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to Dr. L. Lee Smith for all professional bills submitted by him for service rendered me and that this agreement is solely for said doctor's additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee. (Patient Signature) (Date) The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect the said doctor named above. (Attorney Signature) (Date) Attorney: Please date, sign, and return one copy to Dr. L. Lee Smith Keep one copy for your records.

2 The undersigned OFFICE OF INSURANCE REGULATION Bureau of Property & Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided insured person (or guardian of such person) affirms: 1. The services set forth below were actually rendered. This means that those services have' already been provided. 2. Ihave the right and the duty to confirm that the services have already been provided. 3. I was not solicited by any person to seek any services from the medical provider of the services described above. This means that no person has initiated contact with me and/or persuaded me to use the doctor or licensed professional, clinic, or medical institution that provided the services. 4. The medical provider has explained the services to me for which payment is being claimed. 5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500. The undersigned licensed medical professional affirms the statement numbered 1 above and also: A. Ihave not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits. B. r have explained the services rendered to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent. C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner. D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section (15) and (16), Florida Statutes or Section (5)(b)6, Florida Statutes. Insured Person (patient receiving treatment) or Guardian of Insured Person: Name (PRlJVT or TYPE) Signature Date Licensed Medical Professional Rendering Treatment (Signature by his or her own hand): --L. Lee Smith Name (PRlNTor TYPE) Signature Date Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement.ofclaim or an. application containing any false.jncomplete,: or misleading information is guilty of a felony of the third degree' per' :SectionSt7.234(l)(b), Florida Statutes. ' ,.. Note: The origtnal ofthis form must be furnished to the insurer pursuant to Section (4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment O,fthe claim.' '. OIR-Bl /03 _._._-_._.._.---_._----

3 Patient Consent foro Use and Oisc!osure of ProteC"'..ed Haaftnfnfarmation An Boca Chiropracnc Aii Boca Chlropractic's NOTIce of Privacy Practices provides e more complete description of such uses and clsclosures.. have the right to revrs;n me Notice of P~acy Practices prior to signing this consent fl.j! Boca Chiropractic reserves the right to revise ITSNOTIceof Privacy Practices at anytime. A revtsec Notice of Privacy Practices may be obtained by fonrifaming a "witten rscuest to Aff Boca Chirooracfiors Tam; SmITh at An Boca Chiropractic... l.-'vith this consent".~l Boca Chiropractic may call my home or other alternative location and reave is message on voice mail or in person in reference to any items mat assist the practice in canying out TPO, such as appointment remtnders, insurance items and any cans pertaining to my clinical care, including laboratory results among otnsrs.. 'vvith this consent,.al! Boca Chiropractic may mali to my home or other attamative ioc<=.-tionany items that assist the oractice in carrying out TPO~such as: appclrrtment remrnder cards anc patient s=~ements as fong as t~eyaremarked Personal and ConfidennaL Vif1th thls consent,.tv! 80ca Cniropractic may e-{dsii to my heme or other alternative location any items mat assist the practice in canylng OU! TPO, such as eppointment reminder cards and patient stai:&ments. i have +h.o nqr+ to recuest :that jljl Boca Chiropractic restrict how it uses or discloses my PHi to carry out TPO_~H~~~~~;, the p:actice is not required to agree to mf requested rsstnctions, but if it does, it is bound by fuis agreement ~... ~..,.. " am" cnn.'""j;._ ntin..0_ to All B~~ ~Chiinnracnc's tiy SigOH1:9.u lis T01m", - - ~ - r use and disclosure of my- PH: to c;;arrf ot.:-i!po.. ~~ O,~='.,..,..,vconsent in ljmtina except to the ex-..entthat the pracnee has already made disclos:rres in rpav =v "'- l"~ ~.. 11 B. ro. mav ~~!ian~euponmy prior consent ff! de not slgn this consent, Of later revoke it, AI cce,-,nrropractlc ~ decline to provide tr&iment to me.. G.. <:::1 cnaturs of Patient or Legal uarcran ~.::::t all'_ ;..0. Patient's Name

IRREVOCABLE ASSIGNMENT OF BENEFITSIPOLICY RIGHTS PATIENT: I, the undersigned patient hereby assign the rights and benefits of insurance of the applicable personal injury protections, medical

4 IRREVOCABLE ASSIGNMENT OF BENEFITSIPOLICY RIGHTS PATIENT: I, the undersigned patient hereby assign the rights and benefits of insurance of the applicable personal injury protections, medical payments, and/or other insurance to L. Lee Smith, the provider of services and/or supplies rendered for treatment of the personal injuries that were sustained in the accident on (Date) and covered by Personallnjury Protection (PJ.P) Coverage of other insurance coverage in accordance with Florida Statute (5). I,the undersigned patient agrees to pay any applicable deductible or co-payment not covered by the P.I.P or other insurance coverage. I have.read the information herein and is true and to the best of my knowledge. This assignment includes, but is not limited to all rights to collect benefits directly from the insurance company for services that I have received; and all rights to proceed against the insurance company obligated to provide benefits in any action including legal suit, if for any reason the insurance company fails to make payments of benefits of which I am due.. Specifically, this assignment includes the right to collect payment for the reasonable costs connected with copying and mailing records to the insurer at the insurer's request and in accordance with Florida Statute (6). This assignment also includes any right to recover attorney's fees and costs for such action brought by the provider as Patient's assignee. I agree that L. Lee Smith may select any attorney helshelit wishes and understand and agree that the attorney selected by them may be different than the attorney handling my personal injury/bodily injury claim or case. As part of this assignment of rights and benefits, I hereby instruct the insurance carrier that in the event the subject medical benefits are disputed for any reason, including medical reasonableness and or necessity that the amount of benefits claimed by L. Lee Smith is to be set aside and not disbursed until the dispute is resolved. As part of this assignment of rights and benefits, I further instruct the insurance carrier to notify the provider immediately of any dispute as to payment so that he/she/it may exercise their legal rights. I understand that any person who knowingly files anything containing any false, incomplete or misleading information with the intent to injure, defraud, or deceive any insurance company is guilty of a felony of the third degree. I have read the information herein and it is true and correct to the best of my knowledge and belief. PATIENT SIGNATURE DATE PATIENT'S PRINTED NAME PROVIDER: L. Lee Smith, D.C., P.A. The undersigned on behalf ofl. Lee Smith, D.C., P.A. hereby accepts assignment of the insurance rights and benefits for the service rendered to (The Insured) and to be paid directly to L. Lee Smith, D.C., P.A. under (The Insurer) Personal Injury Protection (P.I.P) or other insurance coverage with in accordance with Florida Statute (5). W1TNESS SIGNATURE PROVIDER REPRESENTATIVE'S SIGNATURE IDPAA General Compliance Made Easy

5 TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such carer both to be working towards the same objective. it is essential for Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is-by specific adjustments of the spine. -Health: A state of optimal physical, mental and social well-being, infirmity. not merely the absence of disease or vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alterationof nerve function and interference to the transmission of menta! impulses! resulting in a lessening of the body's innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spina! eveluation, we encounter non-chiropractic or unusual findings r we will advise you. If you desire advice, diagnosis or treatment for those findlnqs, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACITCEOBJECITVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. All questions regarding the doctors objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature, Date, _ AUTHORIZATIONF9R INSURANCE I certify that I have read and understand the enclosed information to the best of my knowledge. The enclosed questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the chiropractor to release any information induding the diagnosis and the records of any treatment or examination rendered to me or my childduring the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractor or chiropractic group insurance benefits otherwise payable to me. I understand that my chiropractic insurance earner may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. X. Dare. _ CONSENT FOR X-RAY I hereby authorize Dr. L. Lee Smith and whomever he designates as his assistant to take X-rays of myself (or said minor). Signature Date, _

6 Payment Authorization I hereby authorize and direct you, my insurance company, and/or, my attorney, to pay directly to Dr. L. Lee Smith such sums as maybe due and owing this office for services rendered me, both by reason of accident or illness, and by any disability benefits, medical payments benefits and to withhold such funds from any disability benefits, medical payments benefits, no-fault benefits, health and accident benefits, workmen's compensation benefits, or any other insurance benefits obligated to reimburse me or from any settlement, judgment or verdict on my behalf as my be necessary to adequately protect said office I hereby further give a lien to said office against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by said office. This is to act as an assignment of benefits and an assignment of direct payment to the extent of the office's services provided. In the event my insurance company is obligated to make payments to me upon the charges made by this office for services rendered, refuses to make such payments, upon demand by me or this office, I hereby assign and transfer to this office any and all causes of action that I might have or that might exist in my favor against such company and authorize this office to prosecute said cause of action either in my name or in the office's name and further I authorize this office to compromise, settle or otherwise resolve said claim or cause of action as they see it. I authorize this office to release any information pertinent to my case to any insurance company, adjuster or attorney to facilitate collection under this assignment, lien and authorization. I agree that the above mentioned office be given power of attorney to endorse/sign my name in any and all checks for payment of my doctor bill. I understand that health and accident insurance policies are an arrangement between and insurance carrier and myself. I understand that I remain personally responsible for the total amounts due this office for their services and will be billed for any account balance. I further understand and agree that this assignment, lien and authorization do not constitute any consideration for this office to await payments and they may demand payment from me immediately upon rendering services at their option. I further understand and agree that if this office must take any action to collect and outstanding balance on my account, I will be responsible for payment of and will reimburse this office for all costs of such collection efforts, including but not limited to all court costs, interest incurred, collection fees and all attorney fees. For office use only: Co-pay is $ --"per visit while under active care toward services rendered. Patient Signature, ~Date _

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PERSONAL INJURY PATIENT HISTORY

PERSONAL INJURY PATIENT HISTORY NAME: DATE: HISTORY DATE OF ACCIDENT: TIME: AM/PM WHO WAS DRIVING THE CAR? PLEASE DESCRIBE THE ACCIDENT IN YOUR OWN WORDS: WERE YOU WEARING YOUR SEATBELT? YES NO DID YOU