By signing this document, you are hereby acknowledging that you understand and agree that at the time of your scheduled injury evaluation you must be in a private area with the ability to be hands free. You agree that this evaluation will NOT be conducted from your car, grocery store, or any public place. Please be advised if you are using a smartphone it must be positioned on a stationary object in order to provide you the ability to be hands free. If you breach any of these conditions, the evaluation will not proceed. If it is discovered during the evaluation that a breach of the conditions have occurred, we will immediately terminate the connection.

Additionally, in order to complete this telemedicine injury evaluation, your device must have a good internet connection, speaker, and a microphone.

Lastly, if you are experiencing or have balancing issues, please have someone with you during the evaluation to assist you so as to avoid any further injury.

All documentation provided must be completed prior to the start of the evaluation.

Review of systems

Injury Questions

I do hereby authorize TeleEMC to furnish my attorney as identified below with full report of any medical records and charges pertaining to my treatment.

I do hereby authorize said attorney to pay directly to TeleEMC such sums that may be due and owing for services rendered to me, and to withhold such sums from any settlement, judgement, or verdict which may be paid to you, my attorney or me as the result of the injury for which I have been treated. I also agree to promptly inform TeleEMC if any other attorney represents me, and that this release and letter of protection will be immediately executed with my new attorney, if charges occur.

If a new release and letter of protection is not immediately executed upon a change of attorney, I agree that my full charges shall become immediately due and payable.

I fully understand that I am directly responsible to TeleEMC for all charges and bills submitted by TeleEMC for services rendered to me. This agreement is made solely for additional protection and consideration of waiting for payment; I also understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually recover said fee.

PATIENT CONSENT AND AUTHORIZATION

I, UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY MY INSURANCE. I FURTHER ACKNOWLEDGE THAT IN THE EVENT TELEEMC IS FORCED TO RETAIN THE SERVICES OF A COLLECTION AGENCY AND/OR ATTORNEY; I WILL BE RESPONSIBLE FOR THE COLLECTION AND/OR LEGAL FEES. I HEREBY AUTHORIZE THE MEDICAL PROVIDER TO RELEASE MEDICAL INFORMATION TO MY INSURANCE COMPANY TO SECURE PAYMENT OF BENEFIT. I ALSO AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS AND AS AUTHORIZATION FOR PAYMENT TO BE SENT TO TELEEMC AT 4800 N. FEDERAL HWY, SUITE B105 BOCA RATON, FL 33431 I HEREBY CONSENT TO THE FOLLOWING TREATMENTS: ADMINISTRATION AND PERFORMANCE OF ALL TREATMENTS, PERFORMANCE OF SUCH PROCEDURES, USE OF PRESCRIBED MEDICATION, PERFORMANCE OF DIAGNOSTIC PROCEDURES/TEST AND CULTURES AS MAY BE DEEMED NECESSARY OR ADVISABLE IN THE TREATMENT OF THIS PATIENT. PERFORMANCE OF OTHER MEDICALLY ACCEPTED LABORATORY TEST THAT MAY BE CONSIDERED MEDICALLY NECESSARY OR ADVISABLE BASED ON THE JUDGEMENT OF THE ATTENDING PHYSICIAN OR THEIR ASSIGNED DESIGNEES. I FULLY UNDERSTAND THAT THIS IS GIVE IN ADVANCE OF ANY SPECIFIC DIAGNOSIS OR TREATMENT. I INTEND THIS CONSENT TO BE CONTINUING IN NATURE EVEN AFTER A SPECIFIC DIAGNOSIS OR TREATMENT. THE CONSENT WILL REMAIN IN FULL FORCE UNTIL REVOKED IN WRITING. I, THE UNDERSIGNED, ACKNOWLEDGE THAT TELEEMC WILL USE AND DISCLOSE MY INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS AS DESCRIBED IN THE NOTICE OF PRIVACY PRACTICE. PHOTOCOPY OF THIS CONSENT SHALL BE CONSIDERED AS VALID AS THE ORIGINAL MEDICARE PATIENTS. I AUTHORIZE TO RELEASE MEDICAL INFORMATION ABOUT ME TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES FOR MY MEDICARE CLAIMS. I ACKNOWLEDGE THAT I HAVE BEEN GIVEN TELEEMC’S NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT IF I HAVE QUESTIONS OR COMPLAINTS, THAT I SHOULD CONTACT THE PRIVACY OFFICIALS. I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS AND CONSENTS FULLY AND VOLUNTARILY TO ITS CONTENTS.

Patients consent, Authorization and assignment of benefits:

I, ASSIGN THE BENEFITS PAYABLE FOR SERVICES TO TELEEMC, I, the undersigned patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my automobile insurance, a/k/a Personal Injury Protect and Medical payments policy of Insurance to the above caption healthcare provider, I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payments at the time services are rendered. I understand this document will allow the provider to file suit against the insurer for payment of the insurance benefits and to seek damages from the insurer per Florida statute 627.428.

Receipt of Notice of Privacy Practices

I have received a copy of TELEMC’s Notice of Privacy Practices. The physicians and staff of TeleEMC have my permission to speak to any family/friends I designate in writing in reference to my medical care.

FLORIDA OFFICE OF INSURANCE REGULATION - Bureau of Property & Casualty Forms and Rates

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

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. 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.
B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
C. The accompanying statement or bill is properly 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.
D. 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(5b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

________________________ _______________________________ ___________
Name (PRINT or TYPE)     Signature                       Date

EMERGENCY MEDICAL CONDITION (EMC)

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment 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.
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.

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(1b), Florida

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

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

NOTICE OF EMERGENCY MEDICAL CONDITION

The undersigned licensed medical provider, hereby asserts:

1. The below patient, has an opinion of this medical provider, suffered an EMERGENCY MEDICAL CONDITION, as a result of the patient’s injuries sustained in an automobile accident that occurred on

2. The basis of the opinion for finding an EMERGENCY MEDICAL CONDITION is that the patient has sustained acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (a)serious jeopardy to patient health; (b)serious impairment to bodily function; or (c)serious dysfunction of a bodily organ or part.

I hereby attest that I am a physician licensed under chapter 458 or chapter 459, a dentist licensed under chapter 466, a physician assistant licensed under chapter 458 or chapter 459, or an advanced registered nurse practitioner licensed under chapter 464, and that the above facts are true and correct.

________________________ _______________________________ ___________
Medical Provider         Signature of Medial Provider    Date

The undersigned injured person or legal guardian of such person asserts:

1. The symptoms I reported to the medical provider are true and accurate

2. I understand the medical provider has determined I sustained and EMERGENCY MEDICAL CONDITION as a result of the injuries I suffered in the car accident

3. The medical provider has explained to my satisfaction the need for future medical attention and the harmful consequences to my health which may occur if I do not receive future treatment.

Injured patient receiving this diagnosis or legal guardian of said injured patient: