Medical History Intake Form (Page 6 of 8) in pdf

Assignment of Benefits In Personal Injury Cases

I authorize Release Chiropractic and Wellness Center to receive lien payment from all liable insurance

companies, attorneys, or myself for all monies due on my account. I understand that all coverage in effect at the time of

my injury will be billed. Any overpayments will be promptly returned to me. In the event that there is no valid coverage

or that I have exceeded my insurance limit, I will remain responsible for charges incurred.

Further, I hereby authorize Release Chiropractic and Wellness Center or any of their employees to sign my

name on the back of any draft or check which they receive from my insurance company for services rendered, whether

pursuant to medical payments coverage or health insurance coverage, as long as I have an outstanding balance with them.

Said amount shall be credited against my account and shall reduce my outstanding balance accordingly.

All fees are based upon individual services rendered, and may vary from visit to visit depending upon the doctors

specific recommendations. A complete list is available at the front desk.

Initial Consultation: This is an opportunity to discuss with the doctor your concerns and their suggestions.

There is no charge for this consultation. (The initial consultation does not include any exams, therapy or X-rays).

Note: Unless all proper claim and insurance information is provided, the patient will be responsible for payment

of care received after the first visit until the necessary information can be validated.

A charge of $25.00 will be assessed for a missed appointment. This fee will require payment at the next visit. We

require a 24-hour notice for cancellations.

If the case is not settled within 120 days of being released from active care, the patient will be

responsible to begin making monthly payments until the balance is paid by the insurance company.

I agree to the terms above, and acknowledge that in the event that there is an outstanding balance, which fails to

be cured within sixty (60) days, my account with Release Chiropractic and Wellness Center will be turned over to

collection. I understand that should this happen, I will remain responsible for any and all additional collection fees and/or

attorney and court costs.

(Please initial to show your agreement.)

______________________________________________

Name

______________________________________________

__________________________

Signature

Date

Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537

Medical History Intake Form Page 6