ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance

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1 ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance Accordance to legislation Bill HB1165-Bill , assignment of health insurance benefits Concerning the payment of health insurance benefits to third persons holding an assignment from a covered person, I hereby instruct and direct the Insurance Company to pay by check made out and mailed directly to: Aim High Chiropractic, PC 50 S. Federal Blvd. Denver, CO Telephone: (303) Fax: (303) HB1165-Bill states The carrier shall honor the assignment and make payment of covered benefits directly to the provider. If the carrier fails to honor the assignment by making payment to the covered person and if the covered person, upon receipt of such payment, fails to pay an amount equivalent to such payment directly to the provider. It shall be the responsibility of the provider to notify the carrier if payment has not been received, in such case, the carrier shall make payment of covered benefits as specified in Section The professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER HB1165- BILL 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 services charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I authorized the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. Patient s Name XX Patient s Signature Date Witness Name Date Witness Signature Date 945 S Federal Blvd., #B 50 S Federal Blvd Chambers Rd, Ste W 44 th Ave th St., #208

2 Aim High Chiropractic 50 South Federal Blvd. Denver, CO Attorney Distribution Authorization Form I hereby authorize my attorney, to release ultimate settlement figures, final disbursement and/or copy of settlement check regarding my auto accident on/injuries on to Dr. at Aim High Chiropractic, PC. Patient Name (Print) XX signed by Patient/Parent/Guardian Date:

3 Auto Accident Information Date and time of accident: Year and make of your vehicle: Year and make of other vehicle that hit you or you hit: Speed of your vehicle: Speed of other vehicle: Position of your vehicle: [] stopped at intersection [] stopped at traffic [] stopped at light [] making a right turn [] making a left turn [] parking [] proceeding along [] accelerating [] slowing down [] other Point of impact: [] rear-end [] head-on [] left front [] right front [] left rear [] right read Visibility: [] poor [] fair [] good Condition of road: [] icy [] wet [] sandy [] dark [] clean & dry Amount damage to your vehicle: $ [] totaled Seat belt on? [] Yes [] No What position of your headrest at time of accident: [] straight [] left [] right Did your body hit the inside of vehicle? [] No [] Yes where? Did you lose consciousness during the injury? [] No [] Yes where? Did the police come? [] No []Yes Ticket given? Y N Written report? Y N Ambulance come? [] No [] Yes Did you go to the ER with them? What was done at the ER? Exam / X-rays / MRI / Other - Did you see any other doctors? [] No [] Yes who? Drawing the accident:

4 Disclosure of Fee s / Payment Policy (Chiropractic) CMT (1-2 regions) $ CMT (3-4 regions) $ CMT (5 regions) $ CMT (extra spinal) $ Neuromuscular Reeducation $ Mechanical Traction $ Manual EMS $ Self-care/Home exercise $ Physician Education/Workshop $ NP Exam, comprehensive(45min) $ NP Exam, 30 mins $ Re-exam expanded(45min) $ Re-exam, Expanded (15min) $ Cervical (2-3 views) $ Cervical (4 views+) $ Thoracic (2 views) $ Lumbosacral (2-3 views) $ Single view of spine $ Biofreeze $26.00 E0190 Cervical Orthopedic Pillow $ Lumbar Orthopedic Pillow $ Therapeutic Exercise $ Electrical Stim. (unattended) $ Therapeutic Activities $ Hot/Cold Pack(s) $ Acupuncture $92.00 Average cost per massage (includes manual traction)$ A9150 Supplement: Combadult 2.5 $16.00 Magnesium 1.0 $12.00 A-Zact 25 $14.00 Baldrian Plus $16.00 Primacal $16.00 Stress Potency Vit.C $13.00 Joints& Stuff $32.00 Bio-CMP $12.00 I have read the above codes and fees and understand the cost of my care with my treating doctor. These Fees are reasonable and customary. I further understand that if my insurance company declines payment, I authorize Aim High Chiropractic, PC to file small claims on my behalf against my insurance company as a method of collection. I further understand that I will be present at the court date if needed. SignXX Print name Date 945 S Federal Blvd., #B 50 S Federal Blvd Chambers Rd, Ste W 44 th Ave th St., #208

5 BY THIS POWER OF ATTORNEY: HEALTHCARE POWER OF ATTORNEY I, (hereinafter, Principal ) of County of, in the state of Colorado, do appoint Aim High Chiropractic, PC (hereinafter, Attorney ), as my true and lawful attorney in fact. In Principal s name, and for Principal s use and benefit, said attorney is hereby authorized to: 1. Endorse any and all checks or forms of reimbursement made payable to principal (or members of principal s family) by any health insurance companies which relate to medical treatment provided by attorney to principal (or members of principals family) over to attorney. 2. Demand and direct any and all health insurance companies, during the course of principal s (or member of principal s family) medical treatment with Attorney on personal injury cases or major medical matters, to make all reimbursement checks for such treatment payable to Attorney and to send such checks directly to attorney. This Special Power of Attorney is created for Attorney s benefit to secure Attorney s right to payment for healthcare services provided and shall be irrevocable throughout the duration of the healthcare services provided by Attorney to Principal arising from any injury or major medical conditions sustained either by Principal or members of Principal s family. GIVING AND GRANTING to said attorney full power and authority to do all and everything whatsoever requisite and necessary to be done relative to any of the foregoing as fully to all intents and purposes as Principal might or could do if personally present. I authorize Aim High Chiropractic to represent my interests in any and all disputes when payment for my claims have not been paid in part or in full. I authorize Aim High Chiropractic to represent me in the event a compliant must be made to the Colorado Insurance Commissioner. All that said attorney shall lawfully do or cause to be done under the authority of this power of attorney is expressly approved. Date: Print Name of Principal XX Principal s Signature 945 S Federal Blvd., #B 50 S Federal Blvd Chambers Rd, Ste W 44 th Ave th St., #208

6 INSURANCE INFORMATION I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. I understand that this Chiropractic Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Chiropractic Office will be credited to my account on receipt. However, 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 to me will be immediately due and payable. CONSENT OF PROFESSIONAL SERVICES AND RELEASE OF INFORMATION I hereby authorize the doctor and whomever he may designate as his assistants to administer treatment, physical examination, x- ray studies, lab procedures, chiropractic care or any clinic services that he/she deems necessary in my case. I further authorize him/her to disclose all or any part of my {patient s) records to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member or employer of the patient for all or part of the clinic s charge, including, and not limited to, hospital or medical services companies, insurance companies, workers compensation carriers, welfare funds, or the patient s employer. MY RESPONSIBILITY FOR PAYMENT OF FEES I fully understand and agree that I am directly and fully responsible to pay this clinic, in full, for all professional services and/or products provided to myself and members of my family. I further understand and agree that such payment to this clinic is not contingent on any settlement, claim, judgement or verdict by which I may eventually recover said fee. I also agree to pay all reasonable costs of collection, attorney fees and interest at the ANNUAL PERCENTAGE RATE of 21% (1.75% PER MONTH) on any PAST DUE BALANCE (over 60 days old). AUTHORIZATION TO RELEASE MEDICAL INFORMATION To: (Provider) Phone: ( ) Fax ( ) I, request the following information: (Patient s name) ( ) X Ray ( ) History ( ) Records ( ) Diagnosis ( ) Treatment ( ) Reports ( ) Billings concerning my: ( ) Accident ( ) Injury ( ) Other To be sent to: For Purpose of: (Specify) According to the Health and Safety Code, these records must be provided within 15 days of receipt of this notice. have read and fully understand the above statements. (Print Name) XX (Signature) I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby and hereby grant permission for my child to receive chiropractic care. (Date) 945 S Federal Blvd., #B 50 S Federal Blvd Chambers Rd, Ste W 44 th Ave th St., #208

7 LIEN AGREEMENT I hereby authorize and direct you, my attorney, or Insurance company to pay directly to said doctors such sums as may be due and owing him/her for chiropractic service rendered to me both by reason of this accident and by reason of any other bills that are due his/her office and withhold such sums from any settlement, judgement, or verdict as may be necessary to adequately protect and fully compensate said doctor. I hereby further give Lien on my case to said doctor against any and all proceeds of my settlement, judgement, or verdict which may be paid to you, my attorney or myself, as a result of the injuries for which I have been treated or injuries in connections therewith. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him/her for service rendered to me and that this agreement is made solely for said doctor s addition protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually recover said fee. I also fully understand that if payment is not made as agreed upon, (customer, buyer, client, etc.) shall be responsible for any and all interest (at 1.75% per month or 21% per annum). All reasonable attorney fees, cost of collection and court costs incurred, in efforts to enforce this agreement. I hereby authorize my attorney to release ultimate settlement figures, final disbursement and/or copy of settlement check regarding my accident/injuries to Aim High Chiropractic. I agree to promptly notify said doctor on any charge or addition of attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this Lien to any such substituted or added attorney(s). Please acknowledge this letter by signing below and returning it to the doctor s office. I have been advised that if my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment but may declare the entire balance due payable. XX Patient s Signature Date Patient s Printed Name Parent or Guardian s Signature Date The undersigned being attorney of record for the above patient does agree to hold such sums for any settlement, judgement or verdict, as may be necessary to adequately protect and fully compensate said doctor and Aim High Chiropractic. Attorney s Signature Attorney s Printed Name Date Please sign, date and return one copy to doctor s office. Also keep a copy for your records. 945 S Federal Blvd., #B 50 S Federal Blvd Chambers Rd, Ste W 44 th Ave th St., #208

8

9 ( ) CHIROPRACTIC ( ) MEDICAL ( ) REHAB ( ) MASSAGE DR / RT / MT: CONFIDENTIAL PATIENT FORM Patient #: Date: PATIENT INFORMATION: Name: Home Phone: ( ) Address: City: State: Zip: Sex: Marital Status: Date of Birth: / / Social Security Number: Name of spouse or nearest relative: Phone #: ( ) Driver's License #: Other ID: address: Occupation: Employer: Work Phone: ( ) Work Injury? Y/ N Employer notified? Y/N Name: Please check the type of care desired: ( ) Lasting Correction ( ) Temporary Relief How did you learn of this clinic? Yellow page / Spanish Yellow Pages / Newspaper / Web Tele-marketing / Sign / Insurance Company / Other: Referred by: AUTO ACCIDENT INFORMATION: Date of Accident / / Time of Accident: AM / PM # of people in vehicle Details of Accident: Do you have an attorney? Y / N Name: Phone: On Lien: Y / N Were you the: Driver Passenger Pedestrian Did you hit the other vehicle: Y / N Were you struck from: Behind Right Side Left Side Front Auto Parked Any tickets issued? Y / N If yes, to whom? Any treatments since the accident? Y / N If yes, by whom? PLEASE DO NOT WRITE BELOW THIS LINE. FOR OFFICE USE ONLY. INSURANCE INFORMATION ATTORNEY INFORMATION 3 RD PARTY INFORMATION MedPay/Uninsured: Name: Insured Name: Claim #: Address: Claim #: Name: Ins. Co.: Address: Address: Phone: Fax: Phone: Notes: Phone: Fax: Fax: Adjuster: Adjuster: Chiro Y / N Limit: Massage: Y / N Limit: Rehab: Y / N Limit: Accu: Y / N Limit: Acceptance of Assignment of Benefits: Y / N Staff Completing Info Date

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