Patient Information

If you are covered under more than one group health policy, please supply the appropriate information.
Si usted tiene más de una póliza que le cubra, favor de proveer la información adecuada.

Please have your insurance card available, so that we can make a copy for our records.
Por favor tenga su tarjeta de aseguranza lista, para que nosotros podamos hacer una copia para nuestros archivos.

I authorize payment of the benefits relating to this claim to be paid directly to:
Yo autorizo el pago de los beneficios relacionados a esta demanda para que sea pagada directamente a:

I clearly understand and agree that all 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 me will be immediately due and payable.

Yo entiendo claramente y estoy de acuerdo que todos los servicios que se me hagan sean cobrados directamente a mí, y personalmente me hago responsable por el pago. También entiendo que si yo paro o suspendo mi tratamiento y cuidado, los honorarios por los servicios profesionales hacia mi persona serán inmediatamente pagados.

Dear Patient: Please complete questionnaire to help us determine whether or not chiropractic care is right for you. If we do not sincerely believe your condition will respond satisfactorily we will not accept your case. Thank you.

Please check the appropriate box for any of the following which you now have or had previously.

THIS IS A CONFIDENTIAL HEALTH REPORT

The undersigned patient and/or responsible party, in addition to continuing personal responsibility and in consideration of treatment rendered or to be rendered, assigns to SHARON JOUBERT-GILBERT D.C., the following rights, now power and authority:

RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to my insurance company, attorney, or insurance adjuster for purposes of processing my claim for benefits and payment of services rendered to me.

IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive irrevocable right to receive payment for such services, make demand in my name for payment and prosecute and receive penalties, interest, court costs, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code, to cooperate, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits upon request.

DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment rendered by the physician/facility named above, you are hereby demanded to pay in full the bill for services rendered by the physician/facility named within 30 days following your receipt of such bill for services to the extent such bills are payable under the terms of the policy. This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing for attorney fees, 18% penalty, court cost, and interest from judgment, upon violation. I further instruct the provider to make all checks payable to IN-LINE CHIROPRACTIC CARE, and to send all checks to P.O. Box 16013, Houston, TX 77222.

THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the Liability carrier to cut a separate draft to pay all services rendered, payable directly to IN-LINE CHIROPRACTIC CARE, and to send any and all checks to P.O. Box 16013, Houston, TX 77222.

STATUTE OF LIMITATIONS: I waive my rights to claim any statute of limitations regarding claims for services rendered or to be rendered by the physician/facility named above, in addition to reasonable cost of collection, including attorney fees and court cost incurred.

LIMITED POWER OF ATTORNEY: I hereby grant the physician/facility named above the power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company representing payment for treatment and healthcare rendered by the physician/facility named above. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my account or addressed upon request in writing to the physician/facility named above.

REJECTION IN WRITING: I hereby authorize the physician/clinic named above to establish a PIP or UM claim in my behalf. I also instruct my insurance carrier to provide upon request to the provider/clinic named above, any rejection in writing as they apply to my lack of PIP or UM coverage. If my carrier is unable to provide said rejection in a timely manner, I acknowledge that I am entitled to minimum levels of coverage, as per section 1952.152 of the Texas Insurance Code, and further instruct my carrier to pay up to available limits directly to physician/clinic named above, and to send any and all checks or financial instruments to P.O. Box 16013, Houston, TX 77222.

TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as requested by my treating doctor at this clinic, he/she has full and complete right to terminate responsibility for my care and relinquish any disability examination within a reasonable period of time. If during the course of my care, my insurance company requires me to take an examination from any other doctor, I will notify the physician/facility immediately. I understand that failure to do so may jeopardize my case.