Dr. Patrick Komeshak / Swansea Chiropractic 3 Park Place, Swansea, IL 62226
In consideration of your undertaking to render care, I, the patient, agree to the following:
Release of Information
1. You, the medical provider, are authorized to release any information you deem appropriate concerning my physical condition to my insurance company, attorney, adjuster or other party necessary in order to process claims for reimbursement of charges incurred by me at your treatment facility.
Right to Receive Payment
2. I, the patient, authorize and assign to you, the medical provider, the right to receive direct payment from my attorney or any insurance company or any other party, who may become obligated to pay me any sums. I further authorize the endorsement of my name to any draft containing my name, to which you are legally entitled, if necessary.
3. In the event any insurance company, attorney or any other person, obligated by contractual agreement to make payment to me for your service charges refuses to make such payment upon demand by you, I, the patient, hereby assign and transfer to you, the medical provider, the cause of action that exists in my favor against any such company or attorney or other person and authorize you to prosecute said action either in my name or your name as you otherwise resolve said claim as you see fit. I, the patient, understand that whatever amounts you do not collect from said insurance proceeds (whether it be all or part of what is due) shall be paid by me.
4. I, the patient, also assign to you, the medical provider, and grant the lien against any and all claims against any third party, whose negligence may have caused my injury, including their insurance, up to the amount of the bill for treatment.
Third Party Insurance Coverage
5. I, the patient, also irrevocably agree to allow you, the medical provider, to bill my personal health insurance company and/or my Med-Pay carrier at the time services are rendered for payment upon demand.
6. I hereby direct my attorney not to interfere with or claim any lien upon any medical payment benefits to which I may be entitled from either my health insurance or medical payment sources. And if any said medical payment checks include my attorney’s name, I direct my attorney to sign his name to these checks for the benefit of the medical provider herein.
7. I, the patient, waive the Statute of Limitations regarding my doctor’s right to recover from me directly.
8. I, the patient, authorize a photocopy or digital copy of this document to be deemed as valid as the original.
Collection of Past-Due Accounts
9. In the event that my account is assigned to a 3rd party collection company or attorney, I accept responsibility for all costs incurred with this process. Associated fees include, but are not limited to, attorney fees, court costs, and filing fees. Additionally, I understand that an annual interest rate of 18% will be applied to accounts after 90-days past-due.
I, the undersigned, have read and agree with the above policy.