Assignment Of Benefits - Allen Chiropractic
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1Allen Chiropractic New Patient Forms
817-416-9800
Assignment of Benefits
The undersigned patient and/or responsible party, in addition to continuing personal responsibility, and in consideration of treatment
rendered or to be rendered, grants and conveys for deferred payment to 1rst Health Group, a lien and assignment against the
proceeds of the patient’s insurance settlement with all the following rights, power, and authority:
RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to my insurance
company, attorney or insurance adjustor for purposes of processing my claim for benefits and payment for services rendered to me.
IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of action that exists in
my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for
such services, make demand in my name for payment, and prosecute and receive penalties, interest, court loss, or other legally
compensable amounts owned by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to
cooperate, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits
upon request.
DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment rendered by the
physician/facility named above within 5 days following your receipt of such bill for services to the extent of such bills are payable
under the terms of the policy. This demand specifically conforms to Sec. 542.057 of the Texas Insurance Code, and Article 21.55 of
the Texas Insurance Code, providing for attorney fees, 18% penalty, court cost, and interest from judgment, upon violation. I further
instruct the provider to make all checks payable to 1rst Health Group, and to 13601 Preston Road, Suite 550E Dallas, TX 75238.
THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the liability carrier to issue a
separate draft to pay in full all services rendered, payable directly to Allen Chiropractic, and to send any and all checks to 1244
William D. Tate Ave, Grapevine TX 76051
STATUTE OF LIMITATIONS: I waive my rights to claim any statute of limitations regarding claims for services rendered or to be
rendered by the physician/facility named above, in addition to reasonable cost of collection, including attorney fees and court cost
incurred.
LIMITED POWER OF ATTORYEY: I hereby grant to the physician/facility named above power to endorse my name upon any
checks, drafts, or other negotiable instrument representing payment from any insurance company representing payment for
treatment and healthcare rendered by the physician/facility named above. 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 my/our address upon
request in writing to the physician/facility named above.
REJECTION IN WRITING: I hereby authorize the physician/clinic named above to establish a PIP or UM/UIM claim on my behalf. I
also instruct my insurance carrier to provide upon request to the provider/clinic named above, any rejections in writing as they apply
to my lack of PIP or UM/UIM coverage. I allege that electronic signatures are not adequate proof of rejection, and are invalid to
establish rejection, and instruct my carrier to provide only copies of my original signature regarding rejection as evidence of rejection
of PIP or UM/UIM.
TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as recommended to me by my
caring doctor at this clinic, he/she has full and complete right to terminate responsibility for my care and relinquish any disability
granted me within a reasonable period of time. If during the course of my care, my insurance company requires me to take an
examination from any other doctor; I will notify this physician/facility immediately. I understand the failure to do so may jeopardize
my case.
By my signature be it known that I have read and fully understand the above contract.
_______________________________
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Patient Name (Printed)
Date
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Patient Signature
________________________________________________
Parent/Guardian Signature
_____________________________________
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Office Manager_
Date
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