Auto Accident/Workers Comp/Slip & Fall

APPLICATION FOR BENEFITS - AUTOMOBILE PERSONAL INJURY PROTECTION

Please complete the following so that we can determine if you are entitled to benefits under the automobile personal injury protection law.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
SSN*
Time and Date of Accident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Tell us briefly how the accident happened*
Signature*

Clear
Date*

MonthDayYear
Date

Letter of Protection - Direction to Pay
Patient Name*
Date of Birth*

MonthDayYear
Date
Attorney Name*

First NameLast Name
Attorney Phone*
Date of Injury*

MonthDayYear
Date
Attorney Name
IMPORTANT: THIS IS A CONTRACT. IF YOU DON'T UNDERSTAND THIS THEN CONSULT WITH AN ATTORNEY BEFORE SIGNING.

Patient authorizes and directs his/her present and any future attorneys related to the above-referenced date of injury {"Attorneys") to honor this agreement. This agreement is made in favor of the above-referenced Medical Provider and shall be termed a "Letter of Protection." The Letter of Protection shall serve to place a continuing lien on any proceeds i recover in any legal action related to the above-reference date of injury. The Direction to Pay applies to Patient's Attorneys.

Background. Medical Providers expects to be paid from any proceeds related to the above-referenced date of injury in exchange for providing medical care/treatment Medical Provider also agrees not to place patient in collections until the resolution of Patient's claims related to the above-referenced date of injury. Patient expects to receive medical care that is reasonable, related to the above-referenced accident and medically necessary. Patient has sustained injuries as a result of injuries related to the above-referenced date of injury and does not have the funds to pay for the medical care which he/she needs. Patient is signing this Letter of Protection in order to receive medical care,

Insurance Benefits. In the event that there are disability benefits, medical payment benefits, No-Fault benefits, health and accidental benefits, worker's compensation benefits, or any other insurance benefits available to Patient besides Bodily Injury and/or Un-insured Motorist (aka Underinsured Motorist) coverage then this Letter of Protection can be used to cover any co payments and/or deductibles.

Protection of Medical Bills. If Patient recovers any money related to the above-referenced date of injury then Patient shall withhold from those funds, sufficient money pay the outstanding balance of any bill(s) owed to Medical Provider. It is understood that Attorney's fees/costs are first-in-line and that this letter of Protection does not interfere with Attorney's retainer agreement with patient. Patient authorizes Medical Provider to provide Attorney with a copy of Patient's medical records, bills, etc. with regard to the above-referenced date of injury.

Patient's Responsibility Regarding His/Her Attorney (present and future). Patient is responsible for informing each and every attorney retained by him/her of the existence of this agreement. Medical Provider has the right to notify Patient's Attorney(s) about the existence of this letter of Protection. Upon request, Patient shall provider status updates about any claims related to the above-referenced date of injury as well as the contact information for any new Attorneys. It is also the Patient's responsibility to advise the Medical Provider at least 10 days prior to collecting any funds and to request a bill for any and all outstanding charges. Patient understands that if funds related to the above referenced date of injury are insufficient to cover the medical bill(s) then Medical Provider has the right to collect the remaining balance.

Disputes. If the patient fails to pay the medical provider's full outstanding balance and Medical Provider is the prevailing party in an action to enforce this Letter Protection then Medical Provider shall have the right to recover all attorney fees and costs including post-judgment proceedings. Binding arbitration is an option if both parties agree in writing.

Direction to Pay. ATTENTION ATTORNEY: THIS IS A DIRECTION TO PAY MY MEDICAL PROVIDER. Patient directs his/her Attorney's to pay an outstanding medical bilfs in connection with the above-referenced date of injury. Patient hereby direct Attorney's to provide a status update in writing within 15 days of receiving a request from Medical Provider.

Effective Date. This agreement becomes effective when the patient signs the agreement below:
SIGNATURE*

Clear
Date*

MonthDayYear
Date

ASSIGNMENT OF BENEFITS/POLICY RIGHTS
I, Name* the undersigned patient have and do assign any and all rights and benefits of insurance of any and all applicable personal injury protection, medical payments and/or insurance to AXIS CHIROPRACTIC & REHAB, INC for services and/or supplies rendered for the treatment of personal injuries sustained in the incidents ofDate of Accident*, to the undersigned patient and covered by Personal Injury Protection (P.I.P) Coverage or other insurance coverage under my policy, in accordance with Florida Statute 627.736. I have read the information herein and it is true to the best of my knowledge and belief. This Assignment includes, but is not limited to, all rights to collect benefits directly from the insurance company for services that I have received and all rights to proceed against the insurance company obligated to provide benefits include legal suit if for any reason the insurance company fails to make payments of benefits to which are due. Specifically, this assignment includes to right to collect payment for the reasonable costs connected with copying and mailing records to the insurer at the insurers at the insurers request and in accordance with Florida Statute 627.736. This assignment also includes any right to recover attorney's fees and costs for such action brought by the providers as patient's assignee. I agree that AXIS CHIROPRACTIC & REHAB, INC may select any attorney of choice and understand and agree that the attorney selected by them may be different that the attorney handling my personal injury/bodily injury claim or case. I hereby instruct the insurance carrier that, in the event the subject medical benefits are disputed for any reason, including medical relatedness, reasonableness, and/or necessity, that the amount of benefits claims by AXIS CHIROPRACTIC & REHAB, INC is to be set aside and not disbursed until the dispute is resolved. As part of this Assignment of rights and benefits, I further instruct the insurance carrier to notify the provider immediately of any dispute as to payment to that he/she my exercise their legal rights. I have read the information herein and it is true to the best of my knowledge and belief.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
PATIENTS OR AUTHORIZED PERSON'S SIGNATURE

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
Signature*

Clear
Date*

MonthDayYear
Date
INSURED OR AUTHORIZED PERSONS SIGNATURE

I authorize payment of medical benefits to the undersigned physician or supplier for services described below.
Signature*

Clear
Authorization for the Release of Medical Records
I hearby authorize Axis Chiropractic & Rehab Center to request a copy of my patient records, CT, MRI Lab Results, or X-Rays containing protected health information. This authorization is given pursuant to Florida Statute 456.057 and HIPAA regulations. I understand that Florida Statute 456.057 (10) makes clear that any third party to whom records are disclosed is prohibited from further disclosing and information in the medical record without the expressed written consent of the patient of patient's legal representative.
Patients Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date

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 treatmentset forth below were actually rendered. This means that those services have already been provided.
2. I have the right and 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 recieving treatment or services) or Guardian of Insured Person:
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

TMJ Symptoms

	Yes	No
When opening and closing your mouth, do you experience pain?
Does your jaw deviate to the right or left when opening?
Do you have popping sounds on the right?
Do you have popping sounds on the left?

Please Check the Appropriate Payment Option
Self Pay  I will be paying cash at the time of service. We accept cash, checks and cards. (All transactions will have a 3% card fee added)
Health Insurance I have health insurance. I will pay my initial deductible in full, if not already met. After my deductible is met I will pay my co-payment and/or percentage. I understand that I am ultimately responsible for my bill if my insurance carrier does not pay including, but not limited to, PiezoWave and DRX 9000 treatments, which are not covered by any insurance carriers at this time.
Workers CompI have been injured at work and have reported my injury to my employer. I have also complied with the necessary requirement set forth by the employer in order to obtain proper authorization for treatment. My claim number is Claim Number and the insurance company handling my case is  Attorney Name.
Auto Accident I have been involved in an auto accident; an accident report has been filed with a police officer. I have contacted my insurance carrier and obtained a claim number. My claim number is    Claim Number   and my insurance company is   Insurance Company   . I understand that I am responsible for my deductible or co-payment.
Auto Accident - No Insurance   I have been involved in an auto accident but do not carry my own auto insurance. The attorney handling my case is .
Slip & Fall*  I have been involved in a slip and fall accident. The attorney handling my case is    Attorney
Signature*

Clear
Date

MonthDayYear
Date
Please attach a photo of your ID*

Cancelof
Please attach a copy of your insurance card*

Cancelof
Should be Empty:

	Yes	No
Had Surgery
Been in any other accident?
Broken Bones
Been Struck Unconscious

	Yes	No
Do you experience pain everyday?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Do changes in the weather affect your symptoms?

	None	Light	Moderate	Heavy
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Water

INSURANCE INFORMATION

HEALTH INFORMATION

PATIENT CONSENT TO X-RAY

VERIFICATION OF NON-PREGNANCY

CONSENT TO X-RAY A MINOR

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

APPLICATION FOR BENEFITS - AUTOMOBILE PERSONAL INJURY PROTECTION

Letter of Protection - Direction to Pay

ASSIGNMENT OF BENEFITS/POLICY RIGHTS

Authorization for the Release of Medical Records

Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service provided

TMJ Symptoms

Please Check the Appropriate Payment Option