Assignment of Benefits

 

Financial Responsibility

 All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits

I hereby assign all benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, auto or any other health/medical plan, to issue payment check(s) directly to CIMA Health of North Miami for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that | am responsible for any amount not covered by

Authorization to Release Information

I hereby authorize CIMA Health of North Miami to (1) release any information necessary to insurance carriers regarding my treatments and condition; (2) process insurance claims generated in the course of examination of treatment; (3) allow a photocopy of my signature to be used to process insurance claims for the period lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from CIMA Health of North Miami on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges by insurance if any incurred in the course of the treatment.

I further understand that fees are due and payable on the date that the services are rendered and agree to pay all such charges insured in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

 

I, {yourFull} do hereby authorize CIMA Health of North Miami to furnish my attorney and/or insurance carrier with copies of his office notes in connection with my treatment, a full medical report of my examinations, copies of my bills and any other documentation that may be needed in order to properly document my injuries/illness. I further authorize and direct my attorney and/or insurance carrier to pay directly to CIMA Health of North Miami such charges, which belong to them for services rendered to me because of the related injury/illness. Moreover, I authorize my attorney to withhold such charges from my settlement, judgment, or verdict that may be paid to said attorney, or myself, as a result of the injury/illness for which I am being treated. I fully understand that I am solely responsible for all my bills submitted by CIMA Health of North Miami for services rendered to me. I also understand that this agreement is made solely for the medical provider, additional protection, and in consideration of his/hers awaiting payment; consequently, I am aware that payments are not contingent on any settlement, judgment, or verdict by which I may eventually win to cover such charges.

 

DIRECCION DE COBRO

Yo, {yourFull} autorizo a CIMA Health of North Miami a proporcionar a mi

abogado y/o compañía de seguros copias de las notas de su oficina en relación con mi tratamiento, un informe médico completo de mis exámenes, copias de mis facturas y cualquier otra documentación que pueda ser necesaria para documentar adecuadamente

Además, autorizó y ordeno a mi abogado y/o compañía de seguros que paguen directamente al proveedor mencionado dichos cargos, que le pertenecen por los servicios que me prestaron debido a la lesión/enfermedad relacionada. Además, autorizo a mi abogado a retener dichos cargos de mí acuerdo, sentencia o veredicto que se pueda pagar a dicho abogado, o a mí mismo como resultado de la lesión/enfermedad por la que estoy

Comprendo perfectamente que soy directamente responsable de todas mis facturas enviadas por CIMA Health of North Miami por los servicios que me brindaron. También entiendo que este acuerdo se hace únicamente para el médico, protección adicional y en consideración de su/ella espera pago; en consecuencia, soy consciente de que los pagos no están supeditados a ningún acuerdo, sentencia o veredicto con el que eventualmente pueda ganar para cubrir dichos cargos.

 

 

I, {yourFull} expressly grant power to CIMA Health of North Miami and its representatives or partners to endorse and deposit into their account any checks and/or drafts payable to the above facility, the patient for medical services rendered by CIMA Health of North Miami due to my motor vehicle accident.

Yo, {yourFull}, entrego expresamente poder a CIMA Health of North Miami. Sus representantes o socios deben respaldar y depositar en su cuenta los cheques y/o otros pagaderos a las instalaciones mencionadas anteriormente; el paciente por servicios médicos prestados por CIMA Health of North Miami debido a mi accidente automovilístico.

I, {yourFull}  acknowledge that I have been provided with CIMA Health of North Miami's "Notice of Privacy Practices" and I'm giving my consent for the use and disclosure of protected health information required and/or permitted by law. CIMA Health of North Miami, in compliance with Federal HIPAA Regulations, is committed to protecting our patients' health information and privacy. Our therapists and staff will be making every effort to ensure that your protected health information ("PHI") is kept private. However, due to the nature of the open setting of our therapy area, your treatment may be performed in the presence of other individuals. In some instances, it is possible that other patients, family members, friends, and staff will overhear information relating to your treatment, diagnosis, and insurance benefits. Unless you indicate in writing to the contrary, by signing this Consent Form you are agreeing that it is possible for other patients to overhear trivial information regarding your treatment and consenting to the disclosure of this inconsequential information to any other individuals who may be present in the therapy area. By signing below, I acknowledge and agree to the

CONSENTIMIENTO DEL PACIENTE PARA USAR Y COMPARTIR INFORMACIÓN PERSONAL DE SALUD Y CONFIRMACIÓN DE RECIBO DE LA NOTA DE PRÁCTICAS

Confirmó que se me ha provisto con la "Nota de Prácticas de Privacidad" de CIMA Health of North Miami, y doy mi consentimiento para usar y compartir Información Personal de Salud como lo permitido y requerido por la ley. CIMA Health of North Miami, de conformidad con los reglamentos Federales de HIPAA, se compromete a proteger la información de salud de nuestros pacientes y la privacidad. Nuestros terapeutas y personal van a realizar todos los esfuerzos para asegurar que su información de salud protegida ("PHI") se mantenga privada. Sin embargo, debido a la naturaleza de la configuración abierta del área de terapia, su tratamiento puede realizarse en presencia de otros individuos. En algunos casos, es posible que otros pacientes,

familiares, amigos y el personal escuchen la información relacionada con su tratamiento,los

beneficios del diagnóstico y de seguros. A menos que indique por escrito lo contrario, al firmar este formulario de consentimiento usted está de acuerdo en que es posible que otros pacientes escuchen información trivial con respecto a su tratamiento y consiente la divulgación de esta información intrascendente para cualquier otra persona que pueda estar presente en el área de terapia. Al firmar a continuación, reconozco y estoy de acuerdo con las condiciones anteriores.

TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PROTECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY MAKES A STATEMENT OF CLAIM CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION, IS GUILTY OF A FELONY OF THE THIRD DEGREE.

IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS COMPLETE AND SIGN THIS APPLICATION 2. SIGN AND ATTACH AUTHORIZATION(S)

3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE

 

I {yourFull} (person or patient naming agent), intend for any agent named in this release to be treated as I would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information and other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Acto of 1996 ("HIPAA"), 42 U.S.C 1320d and

I authorize the disclosure of any information governed by HIPAA to be provided to:

CIMA Health of North Miami

8801 Biscayne Blvd. Suite 105

Miami, FL 33138

Phone: 786-558-4601 Fax: 786-558-4607

 

 Accordingly, I hereby authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has services, to give, disclose and release to any agent who is named herein and who is currently serving as such, without restriction, all of my individually identifiable health information and including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse.

This authority given to any named agent shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The individually identifiable health information and other medical records given, disclosed or released to any named agent may be subject to redisclosure by a named agent and may no longer be protected by HIPAA. The authority given to any named agent herein has expiration date and shall expire only in the event that I revoke the HIPAA Release in writing and deliver it to my health-care provider. There are no exceptions to my right to revoke this HIPAA Release.

Facility Name: CIMA Health of North Miami

8801 Biscayne Blvd. Suite 105, Miami, FL 33138

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1.The services or treatment set forth below were actually rendered. This means that those services have already been provided. INITIAL CONSULT - POST MOTOR VEHICLE ACCIDENT

2.I have 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. 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.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. I have 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. The treatment or services rendered were explained 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 627.732 (15) and (16), Florida Statutes or Section 627.736(5b)6, Florida Statutes. Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1b), Florida Statutes.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

Under Florida Law in accordance with your Insurance Policy, you are responsible for any deductibles and/or co-payments owed. As a result of your treatment by our facility, we ask that you make a good faith attempt at paying these balances as they become due.

We will not unilaterally waive treatment balances owed by you. Any reductions or waivers will be determined by this office on a case by case and as needed basis.

I, the undersigned, understand my responsibility and obligations as stated and do hereby acknowledge receipt of this letter.

It is our understanding that you will be retaining legal counsel regarding the above captioned motor vehicle accident, for which you are currently receiving treatment in this office. Under Florida Law in accordance with your Insurance Policy, you are responsible for any deductibles and/or the (20%) twenty percent co-payment owed. As a result of your treatment by our facility, we ask that you make a good faith attempt at paying these balances as they become due.

As per your directive, we will send all further requests for payment to your legal counsel. Should you change legal counsel, please inform this office immediately so that we can move forward same to the appropriate party. We will not unilaterally waive treatment balances owed to you. Any deductions or waivers will be determined by this office and your legal counsel on a case by case and as needed basis.

I, the undersigned, understand my duties and obligations as stated and do hereby acknowledge receipt of this letter.

 

Thank you for selecting CIMA Health of North Miami for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made.

I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney fees and court costs.

I have read and understand all of the above and have agreed to these statements.

All statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

I, {yourFull} am seeking to receive medical services from CIMA Health of North Miami. I have been informed

by Vitor staff and understand that CIMA Health of North Miami does not take patients who are covered by State Farm Mutual Automobile Insurance Company, State Farm Fire and Casualty Company or their affiliates ("State Farm" By signing this Acknowledgement, I am confirming that I have no insurance coverage from State Farm. I understand that CIMA Health of North Miami is relying upon this acknowledgement in agreeing to provide medical services to me. I agree to give accurate and complete information to CIMA Health of North Miami regarding my insurance coverage and agree to be financially responsible for any charges not

 

INFORMED CONSENT

Please read the entire document before signing. It is important that you understand the information contained in this document. Ask questions before signing if anything is unclear.

The nature of the chiropractic adjustment The primary treatment I use as a Doctor of Chiropractic is spinal manipulation therapy. I will use this procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way that I move your joints. This may cause an audible "pop" or "click" sound, similar to what you have experienced when "cracking" your knuckles. You may feel a sense of movement.

Analysis/Examination/Treatment

As part of the analysis, examination and treatment, you are giving your consent for the use of any of the following procedures, if the doctor deems it medically necessary:

• Spinal manipulation therapy
• Palpation
• Vital signs
• Range of motion tests
• Orthopedic tests
• Basic neurological tests
• Muscle strength tests
• Postural analysis
• Heat/cold therapy
• Mechanical traction
• Radiographic studies
• Manual therapy technique
• Other (please specify)

The material risks inherent in chiropractic adjustment As with many medical procedures, there are certain complications that can arise during chiropractic manipulation and therapy. These complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations and burns. Some types of neck manipulation have been associated with injuries to the arteries of the neck, which can lead to or contribute to serious complications, such as a stroke. Some patients may feel stiffness and soreness during the

first few days of treatment. I will do my best to detect during the examination any contraindication for treatment; however, if there is any condition that does not become apparent during the evaluation, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are uncommon events and usually result from an underlying weakness of the bone, which I evaluate during the collection of your medical history and during the physical and radiographic examination. Stroke has been a topic of much debate. Its incidence is extremely rare, and is estimated to occur in one in a million to one in five million cervical adjustments. The other complications are also considered uncommon.

The availability and nature of other treatment options.

Other treatment options for your condition may include:

• Over-the-counter pain relievers and self-administered rest
• Medical attention and prescription medications, such as anti-inflammatories, muscle relaxants and pain relievers
• Hospitalization
• Surgery

If you decide to opt for any of the treatments mentioned as "other treatment options", you should keep in mind that there are risks and benefits in each option, and it is advisable that you discuss them with your primary care physician.

The risks and dangers attendant to remaining untreated.

Not receiving treatment could allow the formation of adhesions and reduce range of motion, which could lead to a pain reaction and further decrease mobility. Over time, this process can complicate treatment, making it more difficult and less effective the longer it is delayed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW.

I, {yourFull}  have readthe above explanation of chiropractic adjustment and related treatment. By signing below, I declare that I have evaluated the risks involved in the treatment. I have decided that it is in my best interest to undergo the recommended treatment. Having been informed of the risks, I consent to such treatment.

 

MEDICAL BRACE CONSENT FORM

THIS IS TO ACKNOWLEDGE THAT I WAS PROVIDED, BY THE CHIROPRACTOR AT CIMA HEALTH OF MIAMI WITH A MEDICAL BRACE WITH ORTHOSIS WITH RIGID ANTERIOR AND POSTERIOR PANELS; FABRICATED AND OFF-THE- SHELF (IN ACCORDANCE WITH THE HCPS/MEDICARE CODE: LO631 OR L0180.

I,  {yourFull} the undersigned, hereby consent to receive text messages from CIMA Health of North Miami regarding my healthcare.

Purpose of text messages: The text messages may include appointment reminders, health information, billing notifications, and any other relevant communications.

Understanding of Risks: I understand that while text messaging is a convenient way to receive information, it is not a completely secure method of communication. There is a risk that messages may be intercepted by unauthorized parties.

OPT-OUT: I understand that I can opt-out of receiving text messages at any time by replying "Stop" to any message or by contacting CIMA Health of North Miami.

Consent: By signing below, I acknowledge that I have read and understood the above information and consent to receive text messages as described.

 

I HEREBY GIVE MY PERMISSION FOR MY CHILD TO BE TREATED AT CIMA HEALTH OF NORTH MIAMI BY DR. RICHMOND.