cccwalker.com - New Patient Auto Accident

Consent for Treatment
I hereby give my informed consent to receive health care services, evaluation, and treatment rendered according to the applicable standards of care at Colorado Chiropractic and Rehabilitation Center, LLC (hereinafter "CCRC"). I understand that options exist for treatment and all treatments are choices with risks and benefits. If the risks and benefits of a proposed treatment are not clear to me, I understand that I am responsible to request further information from CCRC. The information within my Patient Chart is confidential. I understand that all requests for release of my records, or any portion of my records, must be made in writing to CCRC. Protected health information will only be released with a written authorization, signed by me, and only the minimum disclosure related to my care necessary to fulfill such written request will be provided. I have been provided a copy of CCRC's Privacy Policy Practices and agree to comply with all of CCRC's policies and practices. I understand that I have a responsibility to communicate honestly with my health professionals working at CCRC and to notify them at the earliest time possible of any changes to my condition, health status, re-injury, and/or new injuries and accidents.

I further authorize any health professional working at CCRC to provide tests, procedures, and treatments that are necessary or advisable for the evaluation and management of my health care at CCC and within the scope of CCRC's practice whether rendered by Dr. Walker personally or by another health care provider or staff member under the orders or direction of Dr. Walker.
Patient Signature:*

Clear
Date:*

MonthDayYear
Date
Financial Responsibility Agreement:

CCRC explained and I understand that CCRC offers a "Time of Service Discount" off the normal fees charged for services rendered if payment in full is made at the time services are rendered. By signing below, I choose not to take advantage of the discounted rates. Instead, I authorize CCRC to bill my insurance company (including workers compensation) the normal fees for service.

I also realize that there is a possibility that my insurance company may not pay some or part of fees for certain services rendered by CCRC. CCRC does not promise or guarantee that services rendered to me will be paid by my insurance company. I agree to pay for all charges for services rendered to me if my insurance company reduces or denies payment for any services provided to me by CCRC. Workers Compensation patients with an open claim are not responsible for charges and services rendered if they have an open and accepted Workers Compensation Claim. CCRC will not balance bill services provided to an accepted claim for a Workers Compensation patient who has been provided services by CCRC. Any services provided after a denial of my claim or closure of my claim (without authorized maintenance services) will be my responsibility to pay in full. I am required to notify CCRC if my claim is denied for any reason and contact them to cancel all services immediately. I am responsible to pay any services provided to me after denial of my Workers Compensation Claim.

I UNDERSTAND THAT I AM PERSONALLY FINANCIALLY RESPONSIBLE and obligated to pay, in full, THE ENTIRE BILLED AMOUNT, for any and all health care and/or professional services rendered to me WHETHER OR NOT MY INSURANCE PAYS any portion of the charges incurred by me. I understand that I am personally responsible for any charges, and unpaid portions of charges, not covered by insurance. I understand that amounts unpaid for over 90 days from the date services were rendered are past-due and subject to a monthly finance charge of 1.5% and an annual finance charge of 18%.

I understand and agree that if I fail to make any payments in a timely manner (including but not limited to the balances after insurance benefits and/or settlement proceeds have been received), after such default and upon referral to a collection agency, attorney, or small claims court by CCRC, I will be responsible for all costs of collection, including, but not limited to, collection agency fees up to 50% collection fees, court costs, and CCRC's attorney fees.
Patient Signature:*

Clear
Date:*

MonthDayYear
Date

Assignment of Benefits and/or Proceeds of Claims/Cases/Suits:
I, Name* ("Assignor"), expressly agree that I am personally liable for the entire billed amount for professional services rendered to me at Colorado Chiropractic and Rehabilitation Center, LLC ("Assignee"). Assignor hereby assigns and authorizes payment of all of my major medical insurance benefits, including Medicare, Medicaid, Auto, private insurance, and any other health plan and/or injury settlement, award, or judgment proceeds or benefits due because of liability of a third-party, payable by any party or organization to CCRC ("Assignee") together with any and all rights, privileges, and remedies to payment for health care services provided by Assignee to which I am entitled under any and all insurance and/or settlement proceeds available to me relating to the Loss/Accident/Injury identified above.

This assignment may be revoked at any time by the Assignor in writing accompanied by payment in full of the entire billed amount for services rendered by Assignee, including all interest or finance charges accrued on my account.

This agreement may be revoked by the Assignee if/when benefits under any insurance agreement are not payable due to Assignor's lack of coverage, denial of coverage, and/or violation of policy conditions due to the actions or conduct of the Assignor. I understand that if Assignee revokes this assignment, the entire balance becomes due and payable immediately and pre-payment at the time of service is required for any additional services sought or rendered after such revocation by Assignee.

The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from Assignor for services provided to Assignee for injuries sustained and/or reported to arise from the Loss/Accident/Injury identified above, notwithstanding any agreement to the contrary.

You are directed to pay, directly to Colorado Chiropractic and Rehabilitation Center, LLC, for all professional services rendered to me at Colorado Chiropractic and Rehabilitation Center, LLC. This Direction to Pay is a complete assignment of my benefits and rights under my medical coverage.

Pay To:
Colorado Chiropractic and Rehabilitation Center, LLC TIN: 84-1662392
1700 Bassett St. Unit 816
Denver, CO 80202
Phone: (720) 401-5728 Fax: (303) 567-6256 Email: doctorjen17@gmail.com

Any amounts paid by my insurance or settlement under this Assignment shall be credited to my account with CCRC. I expressly understand that I shall remain personally responsible and financially liable to CCRC for the entire unpaid balance for any services not covered or paid by insurance and/or injury settlement, settlement, judgment, verdict, award, collection proceeds, or benefits due because of liability of a third- party, payable by any party or organization.
Patient Signature:*

Clear
Date: *

MonthDayYear
Date
Authorization to Release Records, Doctor's Lien, and Assignment of Proceeds:
Patient's Name:*
Date of Injury:*

MonthDayYear
Date
Date:*

MonthDayYear
Date
Attorney/ Firm:*
Phone Number:*
Please enter a valid phone number.

I, Name*, hereby authorize Colorado Chiropractic and Rehabilitation Center, LLC/ Jennifer G. Walker, D.C. (hereinafter "CCCR"), to furnish my Attorney/Firm, named above or any successor Attorney/Firm, with a full report of my examination(s), diagnosis(es), treatment, prognosis, etc. regarding the Accident/Claim/Injury I assert was the cause of the injury(ies) for which I am seeking treatment with CCRC.

I further authorize and direct my Attorney/Firm to pay directly to CCRC all sums that are due and owing as described in the Financial Responsibility Agreement above both by reason of the Accident/Claim/Injury and by reason of any other bills and interest or finance charges that are due and to withhold such sums from any settlement, judgment, verdict, or award as may be necessary to fully compensate CCRC.

I hereby give a Doctor's Lien on my claim/case/action to CCRC against any and all proceeds of my settlement, judgment, verdict, or award which may be recovered as a result of the Accident/Claim/Injury for which CCRC has treated me and any other bills and interest or finance charges described in the Financial Responsibility Agreement above.

I fully understand that I am directly and fully responsible to CCRC for the billed amounts of all bills submitted by CCRC for services rendered to me plus any accrued interest or finance charges and that this agreement is made solely for CCRC's benefit and additional protection and in consideration of CCRC awaiting payment and forbearing their rights to pursue legally available actions to collect payment. I expressly understand that such payment is NOT contingent on any recovery by me from any source and that I remain fully responsible under the Financial Responsibility Agreement above. I expressly waive the defense of Statute of Limitations as it pertains to any claim or suit filed against me by CCRC or its successors to collect this debt. I agree to promptly inform CCRC of any change or addition of attorney(s) retained by me in connection with this Accident/Claim/Injury, and I instruct my attorney to do the same and to promptly deliver this Lien to any such additional or substituted attorney(s).

I have been advised and understand that if my Attorney/Firm does not agree to cooperate in protecting CCRC's interests by signing this Lien Agreement, CCRC will not await payment but may declare the entire balance immediately due and payable as well as require pre-payment at the time of service for any treatment.
Patient Signature:*

Clear
Date:*

MonthDayYear
Date
The undersigned Attorney expressly agrees:
1. To expressly comply with the above agreement(s),
2. To withhold and pay to CCRC from the proceeds of any settlement, judgment, verdict, award, collection, and/or insurance payments the amount of CCRC's outstanding account balance, after contacting CCC, or their billing representative, for the most up to date balance including interest and finance charges,
3. Advise CCRC within ten (10) days of their request, the status on the above referenced claim/case,
4. Promptly notify CCRC of any changes in the status of the claim/case that may preclude, limit. Or otherwise impair full payment of CCRC's charges,
5. Notify any attorney, in writing, who may assume the representation of this patient of this assignment and provide CCRC a copy of that notice.
Attorney Signature:*

Clear
Date:*

MonthDayYear
Date
Attorney Name:*
Firm Name:*
Phone Number:*
Please enter a valid phone number.

Office Policy
- Fees
  I understand that Colorado Chiropractic and Rehabilitation Center, LLC is an independent clinic and sets its own fees for all services to conform to reasonable and customary fees for the services provided through this facility (this includes services provided by Dr. Walker, or any other member of the clinic staff or coverage staff). I understand that fees are subject to change without notice. I understand that a complete list of services and fees are available for my review upon written request.
- Cancelation, Missed Appointment and Rescheduling Policy.
  I agree that I may be charged a fee for any no-show, late cancelation, or rescheduling made less than 24-hours before my scheduled appointment. If you are a Workers Compensation patient, please note that missed appointments, no show or late cancellations (less than 24 hours' notice) are not billed to you but may seriously affect your claim and your ability to continue to treat under your claim with our office.
- Late Fees and Monthly Finance Charges.
  I agree that I may be charged late fees and/or a monthly finance charge if there is any outstanding balance owning on my account for over 30 days.
- Time of Service Discount Option.
  I agree that, at the sole option and discretion of Colorado Chiropractic and Rehabilitation Center, LLC, I may be offered a Time of Service Discount on services rendered and that this is a reduction from the customary fees for services at Colorado Chiropractic and Rehabilitation Center, LLC. This requires that I pay in full at the time of service (the same day of my service or before my service). If I do not pay in full at or before the time of service, I will be charged the full customary fee for services with no reduction, and I agree that I am personally and solely responsible for the full-billed amount of the services rendered.
- Other Accidents, Injuries, and Claims.
  I understand that if I am involved in a Workers Compensation, Auto Accident, Personal Injury Claim, or Third-Party Claim of any kind after beginning treatment with Colorado Chiropractic and Rehabilitation Center, LLC, any existing financial agreement(s) or Time of Service Discount are suspended and terminate. I understand that I am required to notify Colorado Chiropractic and Rehabilitation Center, LLC. I further understand and agree that Colorado Chiropractic and Rehabilitation Center, LLC, may unilaterally terminate any financial agreement(s) or Time of Service Discount at any time for any reason with written notice.
My signature below confirms I read, understand, and expressly to adhere with and agree to be bound by Colorado Chiropractic and Rehabilitation Center, LLC's Office Policy and all terms and conditions herein.
Patient Name:*

First NameLast Name
Patient Signature:*

Clear
Date:*

MonthDayYear
Date

Colorado Chiropractic and Rehabilitation Center, LLC

New Patient/ Injury Form

Insurance/ Payment Information:

Consent for Treatment

Assignment of Benefits and/or Proceeds of Claims/Cases/Suits:

Authorization to Release Records, Doctor's Lien, and Assignment of Proceeds:

Office Policy

FACTS OF COLLISION:

OTHER DRIVER INFORMATION:

YOUR INSURANCE INFORMATION:

PHYSICAL INJURIES, IMPAIRMENT AND DAMAGES:

YOUR EMPLOYMENT:

Family History

Hobbies, Habits and Interests:

Medications, Allergies, Prior Tests/Imaging and Prior Treatment:

COLORADO CHIROPRACTIC AND REHABILIATION CENTER PAIN DIAGRAM

QUADRUPLE VISUAL ANALOGUE SCALE

Pain Disability Questionnaire

Impaired Activities