Referral in Tallahassee, FL

 
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Patient Information

 
 
 
 
 
 
 
 
Sex:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Were you injured on the Jon?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If Yes, where/when were x-rays taken?
 
ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR OFFICE BOOKKEEPER.
 
 

Insurance Authorization and Assignment

 
 
I request payment of authorized Medicare/Other Insurance company benefits be made either to me or on my behalf to
 
 
 
for any services furnished my by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.
 
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier of any other insurance company, any information needed for this or a related Medicare/Other Insurance company.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or the agency shown. In Medicare/Other Insurance company assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare/Other Insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare/Other Insurance company.
 
 
 
Date
 
 
 
 
 

Assignment of Benefits Liens and Direct Payment Authorization

MEDICAL PROVIDER: TALLAHASSEE PHYSICAL THERAPY & REHABILITATION SERVICES, LLC
For and in consideration of the above-mentioned provider agreeing to pursue my insurance provider for payment of benefits due to me and not requiring repayment for services. I hereby irrevocably assign to the aforementioned medical provider (the "Provider") and Personal Injury protection benefits in accordance with Florida Statue 627.736(5) my insurance company or any other entity that may be responsible for expenses incurred, and I authorize the Provider to prosecute said action and collect legal expenses as they see fit. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF BENEFITS.

I hereby further give lien to the Provider against any and all insurance benefits named herein and any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illnesses for which I have been treated by the Provider. This is to act as an irrevocable assignment of my rights and benefits to the extent of the services provided. I agree to cooperate with the Provider and an attorney that the Provider chooses, and to do all things reasonable to effect payment of the bills by the insurance company to the Provider including, but not limited to, disclosing patient's medical condition and treatment. This assignment concerns only bills for the Provider and those costs (including, but not limited to attorney's fees, court costs, and interest necessary in procuring payment by the above-named insurance company, etc.).

This assignment is not intended to assign any other causes of action that may belong to the undersigned patient. I agree to pay any applicable deductible or co-payment not covered by the PIP insurance coverage. I understand that this is a benefit and convenience to me in that the Provider will pursue collection against the insurance company on my behalf. I hereby instruct and direct my insurance to pay by check, made out and mailed to the Provider at the address listed above. If my current policy prohibits direct payment to doctors, then I hereby instruct the direct you to make checks payable to me and mail it to the Provider. This agreement is intended to serve as an assignment of the patient's benefits under his/her aforementioned insurance policy to the Provider. If any language within the agreement has the effect of invalidating this assignment, that language shall be deemed void and the assignment shall remain in full force and effect. A photocopy of this assignment shall be considered as effective and valid as the original.

Patient further agrees that should the invoices for services rendered fail to be paid by the insurance provider or the patient and said invoice for services is referred to any attorney for collection the Patient shall be responsible for the attorney fees and court costs.
 
 
 
Date
 
 
 
 
 
 
Date
 
 
 
 
 

Authorization for Release of Medical Information

 
 
 
Date
 
 
 
This authorization or photocopy hereof, will authorize you to furnish all information you may have regarding my condition while under your observation or treatment, including the history obtained, x-rays and physical findings, diagnosis, and prognosis. This information may include office notes or hospital records.
 
 
 
 
 
 
Date
 
 
 
 
 

RE: Patient Records and Physical Therapist Lien

I DO HEREBY authorize the above named Physical Therapist to furnish you, my attorney, with a full report of my case history, examination, diagnosis, treatment, and prognosis of myself in regards to my accident, which occurred on
 
 
 
Date
 
 
 
I DO HEREBY give a lien to said Physical Therapist on any settlement, claim, judgment, or verdict, as a result of said accident and authorize and direct you, my attorney, to pay directly to said Physical Therapist such sums as may be due and owing him or her for services rendered to me and to withhold such sums from settlement, claim, judgment, or verdict as may be necessary to protect said Physical Therapist adequately.

I FULLY understand that I am directly and fully responsible to said Physical Therapist for all bills submitted for services rendered to me and that this agreement is made solely for said Physical Therapist's additional protection and in consideration of his or her awaiting payment. I further understand that such payment is not contingent on any settlement, claim, judgment, or verdict by which I may eventually recover said fee.

THE UNDERSIGNED, being attorney of record for the above named patient, does hereby acknowledge receipt of the above lien and does agree to honor the same to protect adequately said above named Physical Therapist.

PATIENT MEDICAL HISTORY

 
 
 
 
 
 
 
 
 
 
 
 
Do you now have, or have you ever had any of the following medical conditions (please check):
 
 
diabetes
 
 
 
 
 
 
 
 
 
 
 
 
pacemaker
 
 
 
headaches
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
pregnant
 
 
 
allergies
 
 
 
 
 
 
hernia
 
 
 
seizures
 
 
 
 
 
 
asthma
 
 
 
cancer
 
 
 
I have had one or more of the following tests (please check and write in applicate date):
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you answered “yes” to any of the above, please explain below and give the approximate dates:
Please list all medications and the reason for taking them (including over-the-counter medications):
THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
 
 
 
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