Patient Information Form

Please correct the errors described below.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I u understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.

Release of Information

Release of Information: I hereby authorize this provider to: furnish an insurer, an insurer's intermediary, the patient's other medical providers, and the patient's attorney via mail, fax, or email, with any and all information that may be contained in the medical records to obtain insurance coverage information (declaration sheet policy of insurance) in writing and telephonically from the insurer request from any insurer all explanation of benefits (EOBs) for all providers and non­redacted PIP payout sheets obtain any written and verbal statements the patient or anyone else provided to the insurer", obtain copies of the entire claim file and all medical records, including but not limited to, documents, reports, scans, notes, bills, opinions, X-rays, and MRIs, from any other medical provider or any insurer. The provider is permitted to produce my medical records to its attorney in connection with any pending lawsuits. The insurer is directed to keep the patient's medical records from this provider private and confidential and the insurer is not authorized to provide these medical records to anyone without the patient's and the provider's prior express written consent.

Financial Policy

Signing this form allows Mobility Spine and Sports to treat you, and bill any insurance's you may have, share information with other health care offices/facilities, and collect on your account.

Co-payments, Co-insurances, Deductibles, and Non-covered services are the responsibility of the patient/guarantor and expected at the time of service.

I authorize treatment by the providers of Mobility Spine and Sports. I authorize the release of any information requested by insurance companies or liable third parties and I assign all benefits or injury benefits to Mobility Spine and Sports. If the correct insurance is not provided or the proper referral is not obtained, then the patient acknowledges full responsibility for the bill.

I acknowledge that I received or read a copy of the Pllotice of Privacy Practices, which are posted in the waiting room.

I hereby understand the financial policy of this office. I guarantee payment of all charges incurred for the account of the below patient. I further agree to pay all reasonable Attorney's Fee, Collection Agencies Fee, court costs, and any other collection related fees incurred on my account. I also understand that my employer may be contacted to verify employment status.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Assignment of Benefits

The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim that contain or are accompanied by language releasing the insurer or its insured/patient from liability unless there has been a prior written settlement agreed to by the health provider (specifically the office manager) and the insurer as to the amount payable under the insurance policy. The insured and the provider hereby contests and objects to any reductions or partial payments. Any partial or reduced payment regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted.

I, the undersigned patient/Insured knowingly, voluntarily, and intentionally assign the rights and benefits of my automobile Insurance. a/k/a Personal Injury Protection (hereinafter PIP), and Medical Payments policy of insurance to the above health care provider. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered. I understand this document will allow the provider to file suit against an insurer for payment of the insurance benefits or an explanation of benefits and to seek §627.428 damages from the insurer. If the provider's bills are applied to a deductible, I agree this will serve as a benefit to me and I authorize and request such litigation. This assignment of benefits includes the cost of transportation, medications, supplies, overdue interest, and any potential claim for common law or statutory bad faith/unfair claims handling. If the insurer disputes the validity of this assignment of benefits then the insurer is instructed to notify the provider in writing within five days of receipt of this document. Failure to inform the provider shall result in a waiver by the insurer to contest the validity of this document. The undersigned directs the insurer to pay the health care provider the maximum amount directly without any reductions & without including the patient's name on the check. To the extent the PIP insurer contends there is a material misrepresentation on the application for insurance resulting in the policy of insurance is declared void, rescinded, or canceled, I, as the named insured under said policy of insurance, hereby assign the right to receive the premiums paid for my PIP insurance to this provider and to file suit for recovery of the premiums. The insurer is directed to issue such a refund check payable to this provider only. Should the medical bills not exceed the premium refunded, then the provider is directed to mail the patient/named insured a check which represents the difference between the medical bills and the premiums paid. I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts and for any other services unrelated to the automobile accident. The health care provider is given the power of attorney to: endorse my name on any check for services rendered by the above provider, and to request and obtain a copy of any statements or examinations under oath given by the patient.

I certify that: I have read and agree to the above; I have not been solicited or promised anything in exchange for receiving health care; I have not received any promises or guarantees from anyone as to the results that may be obtained by any treatment or service; and I agree the provider's prices for medical services, treatment and supplies are reasonable, usual and customary.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If patient is a minor, Signature of Parent /Guardian

Pain Management Form

The purpose of this agreement is to prevent misunderstandings about certain medications you may be taking for pain management. This is to help both you and your doctor comply with the law regarding controlled substances

I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and my doctor undertakes to treat me based on this agreement. I will not attempt to obtain any controlled medication(s), including opioid pain medication(s), controlled stimulants, or antianxiety medications from any other doctor. I understand that if I break this agreement, my doctor will stop prescribing pain controlling medications. I will communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medication helps to relieve the pain. I will not use any illegal controlled substances, including marijuana, cocaine, etc. I will not share, sell, or trade my medication(s) with anyone. In this case, my doctor will taper off the medication(s) over a period of several days, as necessary, to avoid with-drawl symptoms. Also, a drug-dependence treatment program may be recommended. I will safeguard my medication(s) from loss or theft. I understand that lost or stolen medication(s) will not be replaced. I agree that refills for pain medication(s) will only be made at the time of an office visit during regular business hours. No refills will be available during weekends or after normal business hours. I agree to submit to blood or urine test if requested by my doctor to determine my compliance with my program of pain control medications. I agree to use my medication(s) as directed and understand use greater than as directed may result in being without medication.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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