• 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 set forth below were actually rendered. This means that those services have already been provided.
    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. This means that no person has initiated contact with me and/or persuaded me to use the doctor or licensed professional, clinic, or medical institution that provided the services.
    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.

    The undersigned licensed medical professional affirms the statement numbered 1 above and also:

    1. 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.
    2. I have explained the services rendered to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
    3. The accompanying statement or bill is property 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
    4. 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(5)(b)6, Florida Statutes.

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

  • Clear
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  • Licensed Medical Professional Rendering Treatment (Signature by his or her own hand):

  • Clear
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  • 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(1)(b). Florida Starutes:

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

  • Automobile Accident Questionnaire

  • Accident Information

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  • Insurance Information

  • Assignment of Payment

    My attorney and/or insurance carrier are hereby requested and authorized to pay direct to Comprehensive Physicians Group any monies due on account, the same to be deducted from any settlement made on my behalf. Further, I agree to pay Comprehensive Physicians Group the difference, if any between the total amount of charges on my account and the amount paid by the attorney and/or insurance carrier. It is further understood that I, the undersigned agree to pay Comprehensive Physicians Group the full amount of charges on my account should my condition be such that it is not covered by my policy or if for any reason the insurance carrier refuses to pay my claim.

  • Clear
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  • ASSIGNMENT OF BENEFITS

  • The undersigned patient hereby assigns the benefits of insurance under the automobile insurance with      to Wise Cracks LLC for services rendered to the undersigned patient and covered by Personal Injury Protection (PIP) coverage under   policy with  .
      
    The undersigned further agrees to pay any applicable deductible or co-pay NOT covered by the PIP insurance coverage and/or amount not paid by the insurance company.

    I further understand I am 100% responsible for all fees billed by Wise Cracks LLC, this is to include all charges that may be reduced for "usual and customary". I understand that should my claims be reduced and/or not paid by my appropriate automobile insurance carrier, Wise Cracks LLC will seek legal counsel to obtain his usual and customary, medically necessary fees.

    In addition the undersigned requests that payments for services rendered be issued directly to Wise Cracks LLC, 499 E. Central Parkway, Suite 245, Altamonte Springs, FL 32701.

  • Clear
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  • NECK BOURNEMOUTH QUESTIONNAIRE

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  • Instructions: The following scales have been designed to find out about your neck pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel.

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  • With Permission from: Bolton JE, Humphreys BK: The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. II. Psychometric Properties in Neck Pain Patients. JMPT2002; 25 (3): 141-148.

  • BACK BOURNEMOUTH QUESTIONNAIRE

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  • Instructions: The following scales have been designed to find out about your back pain and how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel.

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  • With Permission from: Bolton JE, Breen AC: The Bournemouth Questionnaire: A Short-form Comprehensive Outcome Measure. I. Psychometric Properties in Back Pain Patients JMPT 1999; 22 (9): 503-510.

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