1 Page 1 of 12 Claim Information Date of Accident Primary(Your Insurance) Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address: Agent Name Agent Phone # 3rd Party(Person that Hit You) Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address: Office Use: Notes
2 Page 2 of 12 ASSIGNMENT OF PROCEEDS AND CONTRACTUAL LIEN In consideration for deferred billing and the services rendered and/or to be rendered, I, the undersigned patient and/or responsible party, hereby irrevocably and exclusively assign and transfer to Tree of Life Chiropractic, Inc. (herein after Provider ) any and all claims, causes of action, and right to any proceeds and/or benefits that I may have against any other person, entity, and/or insurance company for reimbursement and/or payment of the medical charges incurred by me from Provider up to the full amount of the charges and I grant a contractual lien on proceeds of any settlement and/or judgment in any pending or future legal claim or action. THIS ASSIGNMENT AND CONTRACTUAL LIEN IS IRREVOCABLE UNLESS BOTH THE PROVIDER AND I AGREE TO REVOKE IT IN WRITING. I acknowledge that the amount subject to this lien constitutes the ordinary and customary charges by Provider for such services, supplies and/or treatment, and may include administrative charges for costs, expenses and risk of collection typically incurred by Provider. Thus, the amount of the lien may or may not constitute the same charge of such medical services, supplies and/or treatment for similar services to others. I also authorize Provider to prosecute said claim and/or action either in my name or its name, as it sees fit, and further authorize it to comprise, settle, or otherwise resolve said claims as it sees fit. However, Provider shall have no duty whatsoever to prosecute the claim or litigation. Provider shall not be liable for any costs and/or expenses associated with any claims or litigation unless Provider files that litigation. Nothing herein shall prevent me from pursuing any claim or litigation that I otherwise have a right to pursue. However, I will not settle any case or claim involving recovery of Provider s medical bills without the permission of Provider. I understand that whatever amounts Provider does not collect from insurance proceeds (whether it be all or part of what is due), I personally remain responsible and owe and agree to pay the outstanding balance in a current manner. I agree to notify Provider of any payment received by me for medical services from an insurance company or other source, and I hereby instruct my attorney, if any, to likewise notify Provider. Any and all services rendered under this agreement shall be at the sole discretion of Provider and in no way shall this agreement be construed to obligate Provider to provide any services. INSTRUCTIONS TO INSURANCE COMPANIES: I hereby irrevocably authorize, direct and instruct any and all insurance carriers, attorneys, agencies, governmental departments, companies, individuals and/or other legal entity (herein after referred to as payers ), which may elect or be obligated to pay, provide or distribute proceeds to me for any medical conditions, accidents, injuries, or illnesses, past, present, or future (herein after referred to as condition ) to PAY DIRECTLY AND EXCLUSIVELY TO TREE OF LIFE CHIROPRACTIC, INC.; DR. KENNETH R. WILSON II, D.C. such sums as may be outstanding and owed to said Provider for charges incurred by me at the office relating to my condition, with such payment TO BE MADE BY SEPARATE CHECK AND PAYABLE EXCLUSIVELY IN THE NAME OF TREE OF LIFE
3 Page 3 of 12 CHIROPRACTIC, INC.; DR. KENNETH R WILSON II, D.C. and deliver such payment to 309 South Jupiter Road, Suite 100; Allen, Texas Payment directly to me, even if Provider s name is on the check, does not constitute payment to Provider and does not comply with the terms of this agreement. For the purposes of this document, proceeds shall include, but not be limited to, monies/proceeds from any settlement judgment, or verdict, as well as any monies/proceeds relating to commercial health or group insurance, attorney retainer agreements, medical payments benefits, personal injury protection, no-fault coverage, uninsured and underinsured motorist coverage, third-party liability insurance, disability benefits, worker's compensation benefits, and any other benefits or proceeds payable to me for the purposes stated herein. This instruction applies irrespective of whether I have hired an attorney to pursue my other claims. In the event that I retain one or more attorneys to represent my other claims in this matter, I, nevertheless, irrevocably direct any payer (auto insurance and/or health insurance) to directly issue full and separate medical payment to TREE OF LIFE CHIROPRACTIC, INC. INSTRUCTIONS TO ATTORNEYS: In the event that I retain one or more attorneys to represent my other claims in this matter and any settlement proceeds are paid directly to my attorney, I hereby irrevocably instruct my attorney to withhold all such sums and amounts that are outstanding on my account to Provider and remit payment of all such sums fully and directly to Provider contemporaneously with any disbursement of money to me, my attorney, or any other party from said settlement or judgment. I further irrevocably instruct and authorize my attorney to furnish to Provider any documents relating to my insurance settlement and distribution of funds, upon request of Provider, in order that Provider may be made aware of the full settlement disbursement of any recovery I may receive. AUTHORIZATION TO RELEASE INFORMATION: Provider is authorized to release any information it deems appropriate concerning my physical condition and treatment to all payers as defined above or my attorneys to facilitate collection under this assignment. I further authorize and direct all payers to release to Provider all information regarding any coverage or benefits which I may have including, but not limited to, the amount of the coverage, the amount paid thus far, the amount of settlement, and the amount of any outstanding claims. I hereby authorize and direct Provider to file a copy of this assignment, together with any applicable charges, with any or all payers and seek collection of payments, regardless of whether a claim has been established with said payers. I also hereby grant to Provider the limited power of attorney to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company for treatment and services rendered by the Provider. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my/our account or forwarded to me upon request in writing to Provider. DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment rendered by the Provider, you are hereby tendered a demand to pay in full the bill for services rendered by Provider within 30 days following your receipt of such bill for services to the extent such bills are payable under the terms of the policy. This demand specifically conforms to Article of the Texas Insurance Code, providing for attorney fees,
4 Page 4 of 12 18% penalty, court cost, and interest from judgment, upon violation. STATUTE OF LIMITATIONS: In further consideration of deferred billing and the services rendered and/or to be rendered, I waive my right to claim any statute of limitations regarding claims for or collection of the amount due for services rendered or to be rendered by Provider, in addition to reasonable cost of collection, including attorney fees and court cost incurred. This assignment and contract shall not be modified or revoked without the mutual written consent of Provider and myself. I hereby revoke and resend any previously signed authorizations and assignments, whether executed at this office or any other office to the extent that the terms of those authorizations or assignments conflict with the terms of this assignment and contract BY MY SIGNATURE, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND THE ABOVE DOCUMENT AND ACKNOWLEDGE THAT IT IS A VALID AND IRREVOCABLE ASSIGNMENT AND CONTRACTUAL LIEN. Signature of patient and/or responsible parties Signature on behalf of Provider Sworn to and subscribed before me by on, 20. Notary Public in and for the State of Texas My commission expires:
5 Page 5 of 12 AFFIDAVIT I HEREBY AFFIRM THAT I SUSTAINED PHYSICAL INJURIES AS A RESULT OF THE INCIDENT ON. NO ONE HAS OFFERED OR GIVEN ME ANY MONEY, INCENTIVE, REMUNERATION, ANYTHING OF VALUE, OR ANY OTHER FORM OF INDUCEMENT FOR THE PURPOSE OF TREATING AT THIS CLINIC. NO ONE HAS MADE ANY PROMISES OR GUARANTEES WITH REGARD TO MY MEDICAL TREATMENT OR ANY OTHER ASPECT OF MY CASE. I UNDERSTAND THAT I HAVE A CHOICE REGARDING WHERE I SEEK TREATMENT FOR MY INJURIES, AND I HAVE CHOSEN, OF MY OWN FREE WILL, TO SEEK TREATMENT AT THIS CLINIC. Signature of patient and/or responsible parties Sworn to and subscribed before me by on, 20. Notary Public in and for the State of Texas My commission expires:
6 Page 6 of 12 VIA Fax and CMRRR To: Address: Fax: Re: Patient Dear Sir/Madam: When any settlement agreement or any payment is made for this case, please issue a separate check payable to TREE OF LIFE CHIROPRACTIC, INC. for the amount of my outstanding balance with their office and deliver such payment to 309 South Jupiter Road, Suite 100; Allen, Texas I have previously agreed to this in writing and signed an irrevocable Assignment of Benefits and Contractual Lien when I began treatment with TREE OF LIFE CHIROPRACTIC, INC.; DR. KENNETH R. WILSON II, D.C.. Sincerely, Signature of patient and/or responsible parties Date
7 Page 7 of 12 VIA Fax and CMRRR To: Address: Fax: Re: Patient Dear Sir/Madam: It is our understanding that your insurance company may elect or be obligated to pay or provide certain proceeds or benefits to the above referenced patient for medical conditions and treatment related to an incident. For your file, I have enclosed a copy of the signed and notarized Assignment of Benefits and Contractual Lien that the patient has executed. In that document, please take note that the patient gives the following instruction to you: PAY DIRECTLY AND EXCLUSIVELY TO TREE OF LIFE CHIROPRACTIC, INC.; DR. KENNETH R. WILSON II, D.C. such sums as may be outstanding and owed to said Provider for charges incurred by me at the office relating to my condition, with such payment TO BE MADE BY SEPARATE CHECK AND PAYABLE EXCLUSIVELY IN THE NAME OF TREE OF LIFE CHIROPRACTIC, INC.; DR. KENNETH R. WILON II, D.C. and deliver such payment to 309 South Jupiter Road, Suite 100; Alle, Texas I have also enclosed for your file a separate letter signed by the patient with the same instructions. It is our office policy that if a company does not honor our Assignment, Contractual Lien, and patient instructions, and the account is not satisfied by the patient, we pursue all available legal collection efforts against any responsible entity, including direct action against the Insurance company. It is our assumption that your company will honor this valid Assignment,
8 Page 8 of 12 Contractual Lien, and written payment instructions from the patient. If you do not believe that these agreements are valid and legal, or that for some reason you are not required to honor them, please contact our office immediately and put the basis for such decision in writing to us. Thank you for your anticipated cooperation. Sincerely, Dr. Kenneth R. Wilson II, D.C.
9 Page 9 of 12 AUTOMOBILE ACCIDENT HISTORY Name: Age: Date of Birth: M F Address: City: State: Zip: SS#: Driver s License #: Insurance Company: Name of Agent: Address of Insurance Company: Have you retained an attorney? Yes No Name and Address of Attorney: GENERAL SYMPTOMS: Did you hit any part of your body during the collision, for example: head on dash, chest on steering wheel? Yes No If yes, which part and how? Where were you taken after the accident? Were you hospitalized? Yes No If yes, for how long? Did you receive care from any other health care specialist? Yes No If yes, what is the specialist s name? What type of care were you given and for how long? Where did you feel the pain? What are your current symptoms? Have you ever been injured in a similar manner? Yes No If yes, how and when?
10 Page 10 of 12 ACCIDENT HISTORY: Date of Accident: Time of Accident: A.M. P.M. State how accident happened in your own words: What type of vehicle were you in? Make: Year: Were you driving? Yes No Was it your car? Yes No If not, whose? Passenger? Front Back Right Side Left Side Were you rotated in seat? Yes No Were you reclined? Yes No Other: Other people in car? Yes No Names and Addresses: Were they injured? Yes No If yes, explain: Seat belts on? Yes No Shoulder harness on? Yes No Position of Headrest: Was it? Daylight Night Dusk Dawn What were the weather conditions? Were you tired? Yes No Were you awake? Yes No How long had you been in the car?
11 Page 11 of 12 Where were you prior to the accident? What were the traffic conditions? What was the posted speed limit? How fast were you going? Type of road: 2 Lane 4 Lane Gravel Tar Did it happen at a/an: Stop sign Traffic Light Intersection Highway Was your car hit? Front Back Left Side Right Side What damage was done to your car? Inside: Outside: Other: If you struck another car, did you strike it: Front Back Side What was the damage to the other car? Inside: Outside: What condition was the vehicle prior to the accident? Do you have pictures of the involved automobile? Yes No What type of vehicle was involved in the accident? Car Truck Motorcycle Other: Size and Type: Was accident report made? Yes No Police of: City: County: State: Who was ticketed? For what? Did your vehicle strike anything? Yes No If yes, Another car Sign Tree Bridge Hedge An Embankment Other: Size and Type: Were you completely conscious after the impact? Yes No Do you remember the impact? Yes No Did your vehicle go off the road? Yes No If so, Into a ditch? An Embankment? How Deep?
12 Page 12 of 12 Does it bother you to ride in a car now? Yes No If so, as a Driver Passenger State andy strange events that happened during or immediately after the accident. Have you had any time loss from work? Yes No If yes, from to Have you had to have any outside help? Yes No What type? Patient Signature Date Staff Signature
PERSONAL INFORMATION PERSONAL INJURY PATIENT NAME DATE FILE # BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE SOCIAL SECURITY SPOUSE S FIRST NAME EMERGENCY CONTACT ADDRESS PHONE RELATIONSHIP INSURANCE
Welcome to Spooner Physical Therapy! We understand that you have been injured in a motor vehicle accident or other 3 rd party responsible personal injury situation. It is our goal at Spooner Physical Therapy
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