Agreement and Authorization Form

In consideration of the Agreement of Advanced Physical Medicine, to provide any medical treatment and chiropractic services to the patient, the patient hereby acknowledges and agrees as follows:

Signature   MEDICAL RELEASE OF INFORMATION

I hereby authorize Advanced Physical Medicine to release healthcare and financial data to my insurance carrier(s) and attorney(s). I also authorize Advanced Physical Medicine or his chosen representative to contact me at my home or work by telephone, fax or e-mail concerning appointment times, diagnostic testing results and other information pertinent to my care at this office.

Signature   CONSENT FOR PHOTO/VIDEO RELEASE

 I grant Advanced Physical Medicine to take photographs of me and my property in connection with the above identified subject, I authorized Advanced Physical Medicine, its assign, and transferee to copyright, use of publish the same in print and/or electronically. I agree that Advanced Physical Medicine may use such photographs of me with or without my name and for any lawful purpose.

Signature   ASSIGNMENT OF INSURANCE BENEFITS TO PROVIDER

I hereby irrevocably authorize payment of the chiropractic and medical service benefits otherwise payable to me to be made payable and mailed directly to Advanced Physical Medicine for professional services rendered. NO OTHER THIRD PARTY, including my attorney, should receive payment of my bills except this office for the remainder of this claim. It will be assumed and relied upon that the insurance carrier has agreed to and acknowledges chiropractic and medical coverage and will send payments directly to this office.

For the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize Advanced Physical Medicine/Advanced Chiropractic to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Signature   X-RAY CONFIRMATION FOR FEMALE PATIENTS

This is to confirm that this office advises me that x-rays can be hazardous to an unborn child. If x-rays are required during the course of my care with Advanced Physical Medicine, I will notify the x-ray technician if there is a chance, I may be pregnant.

The undersigned agrees to execute any additional documents necessary to implement the foregoing provisions.

Signature   HIPPA OF NOTICE OF PRIVACY PRACTICES

This is to confirm that I have read and acknowledge this office’s Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan, and direct my treatment, obtain payment from third party payors and conduct normal healthcare operations such as quality assessments and accreditation.