Ambulance/ER Report Medpay Claim # Auto Insurance Declarations Page Workman s Comp Claim # Health Insurance Card Medpay Claim #

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1 OUR POLICY OF CARE AND PAYMENT FOR MVA/PERSONAL INJURY/WORKMAN S COMP PATIENTS Our mission is to deliver the finest treatment possible, performed to your satisfaction. Depending on the case you are filing with this office, payment is due at the time of treatment, unless other arrangements have been made. Please select the case type you are seeking treatment for and provide the necessary documents and information listed below for each case: MOTOR VEHICLE ACCIDENT/MEDICAL PAYMENT (MEDPAY): Please provide the necessary documents and information so that we can verify the benefits under your automobile insurance policy for medical payments. We will bill with the auto insurance company directly. Driver s License Attorney Information Auto Insurance Card Attorney Notification Form Auto Insurance Declarations Page Letter of Direct Payment Form (for 3rd party claims) Accident/Police Report If Covered by Medpay: Medpay Amount Ambulance/ER Report Medpay Claim # Picture(s) of Vehicle Medpay /Bodily Injury Adjuster Info Picture(s) of Patient Injuries Health Insurance Card ATTORNEY SETTLEMENT OR THIRD PARTY: If you were involved in a vehicle accident or workman s comp injury, please provide us with a copy (if applicable) the following documents and information. Once this information is received and verified, we will bill them directly. Until that time, you will be responsible for your bill. Driver s License Workman s Comp Insurance Carrier Auto Insurance Card Workman s Comp Adjuster info Auto Insurance Declarations Page Workman s Comp Claim # Accident/Police Report Attorney Information Ambulance/ER Report Attorney Notification Form Picture(s) of Vehicle and Patient Injuries If Covered by Medpay: Medpay Amount Health Insurance Card Medpay Claim # Medpay /Bodily Injury Adjuster Info CASH/CHECK/CREDIT CARD: We accept cash, check and/or major credit card. An endorsed check or copy of a major credit card (with signature on file) must be submitted upon acceptance of patient care. Payment will be processed before services are rendered and/or settlement of claim. HEALTH INSURANCE: (*** WILL ONLY BE USED IF YOU ARE THE RESPONSIBLE PARTY IN THE ACCIDENT***) Please provide us with your Health Insurance Card so that we can verify your benefits available for chiropractic care. If our services are covered under your plan, we will bill your insurance company directly. You will be responsible for what the insurance does not pay, which may include: Copay: a specific flat fee payment defined in the insurance policy paid by the patient at each visit and each time a medical service is accessed. Deductible: the amount of money you must pay each year before your health insurance plan starts to pay for covered medical expenses. Co-Insurance: the cost-sharing requirement between you and your insurance company, where you are responsible for paying a certain percentage and the insurance company will pay the remaining percentage of the covered medical expenses after your deductible has been met. Driver s License/Identification Card Health Insurance Card HRA/HSA Information

2 RELEASE OF AUTHORIZATION AND LETTER OF PROTECTION I,, (patient/client) hereby authorize this office to furnish my Attorney (attorney), and/or Insurance Company (insurance company name), or the designee of either, any medical information requested concerning the condition or treatment of injuries sustained by me and/or my children, on (date). I authorize and direct my attorney to pay from any insurance or other proceeds for any recovery made as a result of said injury; any unpaid balance due said doctor for professional services as a result of any treatment to myself, or my children. I understand that this in no way relieves me of my personal primary responsibility to pay my doctor for service when a statement is rendered and that I will receive customary billing for said services. I authorize my attorney or any third party liability carrier to disclose the settlement status, settlement statement and/or a copy of the settlement check if requested for our purposes. At the time of the settlement, the attorney is instructed that this office shall be furnished separate checks for the medical services which they have rendered for full balance due at that time. Upon settlement of the underlying, the attorney s office will disburse funds directly to Dr.Nailah Smith. The patient hereby acknowledges that should the net recovery to the patient not be sufficient to pay in full all amounts due this office with respect to the above stated matter, then the patient shall remain personally responsible for any unpaid balance. 1. I understand that I am being treated for injuries sustained in a motor vehicle accident and that failure to keep my appointments may jeopardize the insurance carrier s responsibility for medical costs and/or compensation for pain and suffering. 2. I understand that this office is extending me credit for treatment and that if I miss two (2) office visits without a reasonable excuse all bills may be due immediately. 3. I understand that if I sever ties with my attorney before settlement or my attorney will no longer represent my case, all bills may be due immediately. 4. Once released from care, if my case is not settled within six months I will begin making payments of $ a month to this office toward my bill. 5. If my bill is not paid within 10 days after the settlement, my balance will then be doubled. 6. I further understand that if my account is placed in collection status for non-payment or forwarded to a collection agency that I will be assessed a fee of 33% of my current balance. 7. No bills and/or records will be released until the patient has a zero balance and/or our office has an Attorney Notification Form signed by all parties, as our office is extending our services as a credit until a final settlement is met. Therefore, all medical records and bills are the property of Full Body Rejuvenation Center, until the patient s balance is paid in full. PATIENTS SIGNATURE: DATE: SOCIAL SECURITY #: FULL BODY REJUVENATION CENTER 3636 Panola Rd. Suite B Lithonia, GA

3 ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE I hereby instruct and direct the Insurance Company to pay by check made out and mailed directly to: Full Body Rejuvenation Center Dr. Nailah Smith, D.C Panola Rd. Suite B Lithonia, GA The Insurance Company acknowledges the assignment of benefits on file and will pay what is reasonable and customary in the state of GA for medical bills incurred due to the Automobile Accident, WC or PI caused by their client on (date). If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct you to make out the check to me for the medical or chiropractic expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for medical services rendered and mail it to: Full Body Rejuvenation Center Dr. Nailah Smith, D.C Panola Rd. Suite B Lithonia, GA 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 medical service charges over and above this insurance payment. A photo copy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information of pertaining to my case to any insurance Company, adjuster, or attorney involved in this case. Dated at this day of 20. Signature of Policyholder Signature of Claimant, if other than Policyholder

4 Date: ATTORNEY NOTIFICATION Patient s Name: DOB: Address: SS #: Home Phone #: Cell Phone #: Work Phone #: Date of accident: Name of Attorney: Address: Phone Number: Fax Number: I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me by Dr. Nailah Smith, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies. I authorize my Attorney, (attorney name), to distribute to Dr. Nailah Smith payment for all medical services prior to distribution of my settlement to me. I further understand that if my case does not settle in days that I will be obligated to make monthly payments of $ to Dr. Smith until my balance is paid in full or when my case is settled. I understand that I will be assessed a fee of 33% of my current balance should my account be forwarded to a collection agency. Signature of Patient: Date: Signature of Doctor: Date: Signature of Attorney: Date:

5 AUTO ACCIDENT/PERSONAL INJURY/WORKMANS COMP VERIFICATION FORM Date: Patient s Name: DOB: SS#: Address: Home Phone #: Cell Number #: WHAT TYPE OF CASE ARE YOU SEEKING TREATMENT FOR? AUTO ACCIDENT - PERSONAL INJURY - WORKMANS COMP ACCIDENT/INJURY VERIFICATION Date of accident: Who was at fault: Type of Injury: How much damage to your vehicle? Mild Moderate Severe Totaled Total amount of damage to your vehicle? $ How much damage to other party vehicle? Mild Moderate Severe Totaled Total amount of damage to other vehicle? $ Was injury reported to auto insurance? YES NO Who was injury reported to? Have you been treated for your injuries by someone else? YES NO If so, whom: PATIENT INFORMATION Name of Auto Insurance or Workman s Comp Insurance Carrier: Phone Number: Policy Number: Claim Number: Name of Adjuster: Phone Number : Address: Fax Number: DO YOU HAVE MEDPAY ON YOUR AUTO POLICY? HOW MUCH MEDPAY IS ON YOUR AUTO POLICY? Is there an attorney involved? Yes No If so, name of Attorney: Address: Phone Number: Fax Number: I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me by Dr. Nailah Smith, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies. I authorize my insurance carrier,, to provide Dr. Smith s office the information listed below for billing my Auto Accident/Personal Injury/Workman s Comp Medical Claim. I further understand that if my account becomes delinquent that I will be assessed a 33% of my balance as a delinquent fee. Signature: Date: OTHER RESPONSIBLE PARTY (3 RD PARTY INFORMATION) WORKMAN S COMP AUTHORIZATION Name of Person Giving Authorization: Title: Claim Number: Adjustor s Name: BILLS ARE SUBMITTED TO: Name: Phone Number: Address: Fax Number: Number of visits authorized? Will this include physical therapy (modalities)? Yes No Will we need to call before/after each visit? Will you accept patient authorization of Direct Payment to Doctor? Yes No Any Special Billing Instructions: Signature: Date:

6 FULL BODY REJUVENATION Dr. Nailah Smith 3636 Panola Road, Suite B Lithonia, GA [IMPORTANT NOTICE PLEASE READ] AUTOMOBILE INSURANCE MED PAY BENEFITS Many people have medical benefits (medical payments coverage or Med Pay ) included in their automobile policies. This benefit would be listed on the Declarations Page (The Dec Page ) of your insurance policy and it might also appear on the insurance card that you are required to carry as proof of insurance. Our office encourages you to use these benefits since you are already paying for them and since this is exactly their intended use: to provide for your needed medical care without your incurring any penalty, or having to pay a deductible. Here are several reasons why we recommend that you use your med pay benefits: 1. Med Pay is exactly like health insurance in that using it does not cause your rates to increase. If your rates do increase it is not because you filed your med pay. Instead it is likely that: (a) the accident was determined to be your fault by your insurance company; (b) you received a police citation at the time of the police report; (c) you have been involved in numerous reported auto accident s within a brief period of time and you are now considered a high risk. 2. Filing your Med Pay does not relieve the other party from having to pay in full for your loss. Filing Med Pay will help to insure that you are not left to pay medical bills if the other driver s insurance company refuses to make payment to you for any reason. 3. According to Georgia Law, an insurance company cannot increase an auto insurance premium or even cancel the insurance policy as a result of the insured being involved in a multi-vehicle auto accident; so long as the insured was not at fault for the accident. 4. We do not charge for filing your Med Pay. IMPORTANT NOTICE: For these same reasons, our office also recommends that you file your health insurance. The important thing to remember is that you are not guaranteed of receiving full payment from the other driver s liability insurance company. Filing both your med pay and your health insurance will help to ensure that you are not left to pay the medical bills. OUR OFFICE FINANCIAL POLICY As long as our office is filing your med pay and health insurance and as long as these companies are continuing to cover your charges, we will waive collection of payment from you at the time of service. If we receive overpayment on your account we will be happy to refund you the difference, provided we are not under a duty to refund the insurance company.

7 PAYMENT AGREEMENT I understand that I am being treated for injuries sustained in a motor vehicle accident. I am aware that I do not have medical coverage benefits (Medpay) on my automobile insurance policy which is the primary insurance in the event of an automobile accident. I further understand that my health care insurance becomes my secondary insurance in the event of an accident; however your insurance company may not cover chiropractic care and they are not responsible for any bills incurred due to a motor vehicle accident that are on an attorney lien or may be in the process of litigation and may deny all claims. After reading the above statements I am fully aware that I am responsible for any bills incurred for the treatment due to the motor vehicle accident and I am also aware that Full Body Rejuvenation Center is extending me a credit for treatment until my settlement is complete. Once released from care and I have settled my case I agree to come in within 10 days and pay my balance in full. Patient Name Signature Witness

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