I understand and agree that health and accident insurance policies are an arrangement between insurance carriers and my self. Furthermore, I understand that the Doctor’s Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized should be paid directly to the Doctor’s Office will be credited to me account on receipt. However, I clearly understand and agree that services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. In the event my account is past due for 60 days from the date of service, and is turned over to an attorney for collection, I will also be liable for attorney’s fees in the amount 1/3 of the principal balance, plus court costs.
1. Reason for seeking chiropractic care
Please mark the location of your pain or discomfort on the images below. Use symbols shown to represent type (s) of pain.
D–DULL, S–STABBING, B–BURNING, T-TINGLING (PINS & NEEDLES), N–NUMB, C-CRAMPING
I understand that, under the Health insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information will be used to:
*Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
*Obtain payment from third party payers.
*Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more description of the uses and disclosures of my health information. I understand that this organization has the right to charge its Notice of Privacy Practices from time to time and that I may contact the organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment and health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide such restrictions.
I attempted to obtain the patient’s signature in acknowledgement on the Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below.
I do hereby authorize ASCENT INTEGRATED MEDICINE to furnish you, my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc. of myself in regard to the accident in which I was recently involved.
I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for medical 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 to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds from my settlement, judgment, or verdict which may be paid to you, my attorney, or myself, as a result of the injuries for which I have been treated or injuries in connection therewith.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent upon any settlement, judgment, or verdict by which I may eventually recover said fee.
I agree to promptly notify said doctor of any change or addition of attorney(s) used by me in advised that if my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable
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 and fully compensate said doctor above named. Attorney further agrees that in the event this lien is litigated, that the prevailing party will be awarded attorney fees and costs.
Patient understands and agrees that patient is financially responsible to pay for ALL charges incurred as a result of the treatment provided by AIM. If outside collection services or attorneys are employed by this facility for the individual who disregards our office policy, he/she agrees to pay those office charges incurred at AIM plus 18% interest per annum, in addition to and including court costs and attorney fees of 33% of the outstanding balance in the event this file is turned over to an attorney for collection.
To Whom It May Concern:This Irrevocable Assignment of Benefits. Authorization and Lien (this "Assignment") is made by and between (Paitents) and Ascent Integrated Medicine With this Assignment, and in consideration of treatment without having to render concurrent payment. Patient, hereby irrevocably transfers sets over and assigns to Ascent Integrated Medicine all insurance and/or litigation proceeds to which Patient is now or may hereafter become entitled, Including those listed below, up to the total amount due and owing Ascent Integrated Center rendered to the Patient by reason of accident sustain on Type a labelType a labelType a label including interest thereon, as well as any other charges accumulated in conjunction with this accident that are due or may become due the Health Care Provider, including, without limitation, requested reports, collection cost and expenses and attorney's fees, and Patient further hereby irrevocably authorizes and directs any insurance company and/or attorney to whom and original or copy of this Assignment is provided to withhold from Patient and pay directly to such Health Care Provider such amount(s) from (1) any insurance benefits payable to Patient or on Patients behalf, including, but not limited to, medical payment benefits, No Fault benefits, health and accident benefits, personal injury protection benefit, third-party liability coverage, foundation grants, governmental or emergency benefits, worker's compensation benefits or any other insurance proceeds or benefits of any kind which are payable to or on behalf of the Patient, and (2) any litigation proceeds (which may include insurance proceeds) from any settlement, judgment or verdict in Patients favor as may be necessary to fully pay any and all financial obligation owed to the Health Care Provider by the Patient. This Assignment is to be a complete and current transfer of Patients right, title, and interest, separate from any statutory or contractual lien or claim to which the Health Care Provider may also be entitled. Patient acknowledges that Health Care Provider has a substantial pecuniary interest in the enforcement of this Assignment.The Patient further agrees that, in the event the insurance company and/or attorney obligated hereunder to make payments to the Health Care Provider fails or refuses to make payment for the full amount due as set forth above, this Assignments is a full, immediate and complete assignment of all the Patient's rights, title, interest, remedies and benefits in and to the assigned property to the extent of the Health Care Provider any and all causes of action that Patient might have or that might exist in Patients favor against such insurance company and/or attorney with respect to the assigned property. In addition to the foregoing assignment, Patient hereby, authorizes, nominates and appoints as Patients-attorney-in-fact any officer of Health Care Provider, to prosecute said causes(s) of action either in Patients name or in the Health Care Providers name and Patient further authorizes the Health Care Provider to compromise, settle or otherwise resolve said claim(s) or cause(s) of action as it sees fit.In further consideration of the services provided by the Health Care Provider, Patient hereby grants a lien to said Health Care Provider against any and all Insurance benefits and litigation proceeds outlined in the first paragraph above which may be payable to or on behalf of the Patient as a result of the injuries or illness for which Patient has been treated by said Health Care Provider. The Patient further agrees that the statute of limitation is applicable to Health Care Providers right to demand payment from the patient shall be tolled for all reasonable times that negotiation or litigation between third parties and the Patient are ongoing.Patient hereby that Virginia law imposes a lien in the amount of $750.00 upon Patients claim against the individual or entity whose negligence is alleged to have caused Patient injuries.Notwithstanding the foregoing, the Patient agrees that until the Health Care Provider is paid in full, the Patient shall remain personally and fully responsible for and promises to pay the total amount due the Heath Care Provider (including principal, interest, collection costs and attorney's fees of 35%) until fully paid. The Patient further understands and agrees that this Assignment does not constitute any agreement of or consideration for the Health Care Provider to await payment from any source, and in the event the Health Care Provider deems itself in its sore discretion insecure as to the prospect payment, it may demand payments from Patient immediately upon rendering services at its option and proceed to collect same through legal means if necessary.Patient authorizes the Health Care Provider to release this Assignment and any information pertinent to Patient case to any insurance company, adjuster or attorney to facilitate collection under this Assignment. Patient hereby nominates and appoints any officer of the Health Care Provider as Patient's attorney-in-fact to endorse/sign Patient's name on any and all checks for payment of the services provided to Patient by said Health Care Provider.In the event that any part of provision of this Assignment shall be determined to be invalid or unenforceable, the remaining parts and provisions of this Assignment which can be separated from the invalid, unenforceable provision shall continue in full force and effect.Witness the following signatures and seal as of the indicated date:
This Letter, signed by the patient, declares that the patient has NOT provided health insurance information AND/OR not given for our office, The Ascent Integrated Center, to submit all medical charges to the above mentioned HEALTH insurance, despite the efforts of The Ascent Integrated Center to ask for the health insurance information of the patient.
Therefore, our office is submitting all charges related to the auto accident directly to the AUTO insurance.
I hereby authorize Name of Ins. Company Insurance Company to pay by check and mail directly to:
Ascent Integrated Medicine
6521 Arlington Boulevard, Suite 100
Falls Church, VA 22042
If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it to the above named address for the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the 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 the insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
I authorize the doctor to initiate a complaint to the insurance commissioner for any reason on my behalf.
I Name do hereby designate Ascent Integrated Center to full extent permissible under the Employee Retirement Income Security Act of 1974 ("ERISA") and as provided in 29 CFR 2560-503- I (b)4 to otherwise act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any medical or other healthcare expense(s) incurred as a result of the services I receive from the above named doctor. These rights include the right to act on my behalf with respect to initial determinations of claims, to pursue appeals of benefit determinations under the plan, to obtain records, and to claim on my behalf such medical plan reimbursement and to pursue any other applicable remedies.
This letter is to certify that l, Name understand a letter for authorization of absence after release from active by the provider will not be issued on my behalf by the office.If there is a need for an authorization of absence, I will request for it while I am currently on treatment as a result of the accident.