I understand the potential benefits and risks of treatments provided by Advanced Injury Treatment Center,including physical therapy, massage therapy, chiropractic therapy, electrical stimulation, etc. , which may involvehigh-velocity manipulations, mobilizations, internal mobilizations, electrical modalities, hot and cold applications,and exercise programs. I agree to promptly consult my practitioner regarding any questions, concerns, or changesin my condition. I have disclosed all known medical conditions and will inform my practitioner of any updates. Byinitialing here, I consent to treatment by any provider affiliated with Advanced Injury Treatment Center. 

Our HIPAA Notice of Privacy Practices explains how your medical information may be used, disclosed, andaccessed under federal law. By initialing below, you acknowledge that you have been informed of your rightsregarding your protected health information and understand that a copy of our HIPAA policy is available for reviewon-site at any time. You may also request a personal copy of the policy at your convenience.

At Advanced Injury Treatment Center, we are committed to providing advanced and effective medical services,physical therapy, and massage therapy with personalized, one-on-one appointments. Individualized care isessential to your success, and to ensure this level of service, we reserve both space and staff time specifically foryour appointment. Failure to provide 24 hours of notice or a no-call/no-show may result in a $25 fee chargedto the credit card on file. This policy is implemented at the discretion of the treating provider.

Advanced Injury Treatment Center is committed to safeguarding all patient information, including your emailaddress, phone number, and other personal details. By providing your contact information, you consent toreceiving communications from us, such as appointment updates, occasional newsletters, and informative articles.Rest assured, we will never sell, share, or disclose your personal information to third parties. You also retain the rightto easily opt out of any email communications at any time. Your privacy and trust are our top priorities.

At Advanced Injury Treatment Center (AITC), we understand that there are multiple options for funding medicalcare following an auto accident. If you have any questions about these options, we are happy to clarify them basedon your specific situation. Please note that AITC does not accept Medicaid, Medicare, or private health insurance.

AITC acknowledges that you are not personally liable for any medical treatment costs exceeding your settlementamount. You will not be personally billed except in cases where you breach our cancellation policy. By initialing,you hereby authorize and direct your insurance carrier(s), including those providing MedPay, Bodily Injury, UM/UIM, or workers’ compensation benefits, to issue payment directly to Advanced Injury Treatment Center for any andall services rendered.

I acknowledge and consent to Advanced Injury Treatment Center (AITC) including the costs of non-medicalservices, such as administrative fees, medical records requests, transportation coordination, and interpretationcoordination, on my signed lien for continuity of care. These necessary hard costs may be incurred during thecourse of your treatment and will be included in the lien against any settlement, judgment, or insurance proceedsrelated to your case, including MedPay, Bodily Injury, UM/UIM, or workers’ compensation claims. This lien complieswith Colorado Revised Statutes, including C.R.S. § 38-27.5-104 and § 38-27.5-105, which govern healthcareprovider liens and limit recoverable amounts to the net settlement received. You understand that these costs areessential to maintaining your care, and you will not be personally liable for them beyond your settlement amount,except in cases of fraud or misrepresentation.

Advanced Injury Treatment Center, LLC, a Colorado limited liability company and its networked healthcare providers (collectively, “AITC”) and the above-named patient (“Patient”) agree as following regarding the above information and circumstances:

 
AITC hereby agrees to provide medical services and care to the Patient within the scope of AITC’s clinical practice for the Injuries suffered by Patient arising out of the above-described accident or incident and to delay payment for such charges under the terms of this Agreement in exchange for the Patient’s grant to AITC of the Lien, as defined below.  

Patient hereby agrees to grant and grants to AITC a health-care provider lien pursuant to Colorado Revised Statutes, §§ 38-27.5-101 through-108, to secure the payment of all medical care services provided to Patient by AITC for AITC’s treatment of Patient arising out of the above-described Injuries caused by the negligence or wrongful act of another person on any money received as a result of any Claims Patient has asserted or may assert on account of such Injuries against any third party or parties or under an uninsured or underinsured motorist insurance policy (the “Lien”).

AITC agrees that the charges for the medical services and care provided to the Patient under this Agreement underlying the Lien will be at the rate of its usual and customary billed charges, that such billed charges will not be excessive, unreasonable, or inflated and that such billed charges will not be subject to surcharges, finance charges, interest, or other increases in the amount of the Lien above AITC’s usual and customary billed charges.

AITC acknowledges and agrees that the maximum amount that may be collected under this Agreement and Lien by AITC or any assignee of the Lien is the total amount of AITC’s usual and customary billed charges for the medical services and care provided by AITC to Patient and that Patient is not liable for such billed charges if Patient does not receive a judgment, settlement, or payment on his or her claims against third parties or under an uninsured or underinsured motorist insurance policy for Patient’s Injuries and that Patient is not liable under this Agreement and the Lien for any amount in excess of the amount of any net judgment, settlement, or payment, as defined by C.R.S. §38-27.5-102(3),  on his or her claims against third parties or under an uninsured or underinsured motorist insurance policy for Patient’s Injuries. 

Patient represents to AITC that he or she is a resident of the state of Colorado and that, to the best of his or her knowledge, the above information as provided by Patient is true and accurate, that the Injuries are the result of the negligence or wrongful acts of the third parties identified above, and that Patient has no insurance in effect or for which he or she is eligible that would pay for the medical care and services to be provided by AITC under the terms of this Agreement.

 
Patient hereby authorizes AITC to publish notice of the Lien in the statutory lien records of the Colorado Secretary of State which notice will disclose Patient’s name and address, the fact of treatment by AITC, and any other information permitted or required by law concerning statutory liens and which notice and the information contained in it will be accessible to the general public by, among other means, an online computer search of the Colorado Secretary of State’s records. 

Patient further authorizes AITC and any assignee of the Lien to disclose and use all information, including, but not limited to, protected health information, concerning AITC’s care and treatment of and services provided to Patient concerning Patient’s Injuries arising from the foregoing accident or incident, which might include any medical history information that pre-dates the accident or incident, as convenient or necessary for AITC or any assignee of the Lien to enforce and collect on the Lien and to disclose the same information to the Patient’s legal counsel. Patient hereby authorizes his or her below described legal counsel to disclose to AITC any and all information related the Claims requested by AITC or any assignee of the Lien.

Statutory Disclosures:

The Following Disclosures To The Patient Are Required By Colorado Law (C.R.S. §38-27.5-104) And Should Be Carefully Reviewed By The Patient. If There Are Any Questions Or Concerns About The Disclosures, The Patient May Discuss Them With AITC And Should Consider Discussing Those Questions Or Concerns With Patient’s Legal Counsel.  

1. The following are potential methods for payment of billed medical charges (that may or may not be available to Patient):
   
   
   1. The creation of a health-care provider lien;
   2. The use of benefits available from any of the following payers of benefits for which Patient is a beneficiary (a person entitled to benefits) (although AITC does not accept any of the following):
      
      1. an insurer, such as a health insurer or workman’s compensation insurer;
      2. a health maintenance organization;
      3. a health benefit plan;
      4. a preferred provider organization;
      5. an employee benefit plan;
      6. a program of medical assistance under the "Colorado Medical Assistance Act", including Medicaid;
      7. the children’s basic health plan (for Colorado children that do not have health insurance);
      8. any other insurance policy or plan; or
      9. any other benefit available as a result of a contract entered into and paid for by or on behalf of Patient.
      10. Patient can obtain information about any available health-care provider network from the forgoing payers of benefits or AITC. 
   3. Any other payment method or arrangement agreed to in writing by both AITC, or its assignee, and Patient; or
   4. A combination of the payment methods specified in paragraphs (I)(A) through (I)(C), above.
2. AITC and any of its assignees of a health-care provider lien is not a health insurer or a payer of any benefits described in paragraphs (I)(B)(1) through (9), above;
3. Except in the event of fraud or misrepresentation by Patient:
   1. If Patient does not receive a judgment, settlement, or payment on his or her claim for injuries against third parties or under an uninsured or underinsured motorist policy, Patient is not liable to AITC or any assignees of the health-care provider lien (known as the holder of the health-care provider lien) for any portion of the health-care provider lien;
   2. If Patient receives a net judgment, settlement, or payment that is less than the full amount of the health-care provider lien, the injured person is not liable to the holder of the health-care provider lien for any amount beyond the net judgment, settlement, or payment, and the holder of the health-care provider lien may not file a claim (a complaint or counterclaim) against Patient directly to be reimbursed for any amount beyond the net judgment, settlement, or payment. Nothing in this section prevents a health-care provider or its assignee from initiating a declaratory judgment action or participating in an interpleader action or claim pursuant to the Colorado rules of civil procedure, or any other similar action or claim, to determine the Health-care provider's or its assignee's share of the injured person's net judgment, settlement, or payment.
   3. The health-care provider or its assignee may not assign a health-care provider lien to a collection agency or debt collector;
4. AITC’s assignee's compensation from the Patient is based on the difference between AITC's usual and customary billed charges and the amount that the assignee pays to purchase the health-care provider lien;
5. There is no common ownership interest between the holder of the health-care provider lien and Patient’s legal counsel;
6. There is no common ownership interest between any assignee of the health-care provider lien and AITC or any other health care provider who is providing treatment or who may provide treatment to Patient under the terms of the health-care provider lien, although if any person or entity takes assignment of the health-care provider lien, it may retain Continuity of Care Colorado, LLC (“CCC”) to manage and collect the health-care provider lien and AITC and CCC have common ownership. 
7. If Patient has obtained health insurance even after a health-care provider lien has been created, and Patient or Patient’s legal counsel so informs the holder of the health-care provider lien, all future care may be billed to the health insurance carrier at the injured person's discretion.
8. Upon request by Patient or Patient’s legal counsel, the holder of the health-care provider lien shall provide in writing to the Patient an itemized statement of all the billed charges for treatment comprising the total value of the health-care provider lien as the billed charges are accrued, to the extent practicable, and when the health-care provider lien is final. The final itemized statement must include a summary of all treatments provided, the total amounts billed for each treatment, and the total amount of the health-care provider lien due and owing.

The Patient May Discuss Any Questions Or Concerns About The Disclosures With AITC And Should Consider Discussing Those Questions Or Concerns With Patient’s Legal Counsel.  

Statutory Limits on Health-care Provider Liens
Colorado Revised Statutes, §38-27.5-105, imposes certain limitations on what a health-care provider or its assignee may charge or do with respect to a health-care provider lien (the “Statutory Limitations”).  AITC acknowledges and agrees that the Lien is subject to the Statutory Limitations and that AITC and any assignees of the Lien are obligated to act regarding the Lien, including, but not limited to, in enforcing the Lien, in compliance with the Statutory Limitations. 

Patient acknowledges and agrees that AITC may assign or sell the Lien to a third party which is not a collection agency or debt collector. No such assignment or sale by AITC will change any of the terms or limitations on the holder of the Lien (AITC or its assignee or purchaser) concerning amounts that can be collected under the Lien or any other term of this Agreement.

By Signing This Agreement, Patient Acknowledges That The Information In This Agreement Will Become Public, And That The Health Care Information AITC Maintains Concerning The Patient’s Medical Care Covered Under The Lien May Be Disclosed To A Third-Party Purchaser Of Patient’s Lien.

I understand that, to ensure my collision-related treatment is effectively managed at AITC, access to allmedical records pertaining to my auto accident is required. I hereby authorize AITC to request any andall medical records related to my collision and the treatment arising from it by initialing the box to theright of this statement.

I understand that, to ensure high-quality care and assess the impact of collision-related injuries on pre-existing conditions, my physician may need to access medical records predating my collision. Iauthorize the request of any and all relevant records from the facilities listed on this sheet to support my treatment and documentation by initialing the box to the right of this statement.

I understand that AITC participates in COHRIO and may use the COHRIO Portal to access any and allrecords linked to my COHRIO account. I also acknowledge that I have the right to request informationfrom AITC regarding any records obtained through the COHRIO Portal. I authorize AITC to utilize the COHRIO Portal by initialing the box to the right of this statement.

I understand that AITC provides a secure, HIPAA-compliant portal for my legal and case management teams to access all medical records and billing related to my collision. I authorize AITC to utilize thisportal to ensure continuity of care, efficient case management, and effective legal support/guidanceby initialing the box to the right of this statement.

I understand that I have the right to revoke this authorization at any time, provided it is done in writingand submitted to the appropriate party, except in cases where disclosures have already been madebased on my initial consent. I acknowledge that revocation may not be possible if the authorization was used to obtain insurance. Refusal to sign may result in AITC being unable to accept my case.