Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care. In consideration of medical serviced provided to me by Brown Family Chiropractic, P. I Irrevocably assign to BFC Thereafter referred to as "Assignee" any and all insurance benefits available to me including but not limited to health insurance.
Personal Injury Protection PIP benefits, Med Pay benefits, uninsured motorist benefits, underinsured motorist benefits, optional or compulsory bodily injury coverage, general liability coverage and or worker's compensation benefits to the extent of any bills for medical services provided to me by Assignee. In the event there is no such insurance benefits available to cover the Assignee's bills, I further assign to the extent necessary to pay in full the bills of the Assignee, the proceeds of any Judgement, arbitration award or settlement.
In the event the bills of the Assignee are not paid in full by insurance benefits, judgement, arbitration, award, or settlement, I personally agree to pay any outstanding balances owed to the Assignee. The irrevocable Assignment shall in no way limit or abrogate my right to sue any applicable insurer in the event the insurer denies coverage for the Assignee's bills. By the way of the Assignment, I hereby instruct my attorney and or an applicable insurer to pay the medical bills covered by this agreement directly to Brown Family Chiropractic, P.
I agree that a photocopy of the Assignment shall be deemed as effective and valid as the original. My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit. I have read and agree to the above statement. If warranted, a physical examination will be performed that can include but is not limited to vitals measurement, systems evaluation, orthopedic tests, and maneuvers tests that move and stress parts of the body , neurological test tests using sharp or dull instruments, smells, or sounds, gently tapping as well as physical touching.
These test and maneuvers will help the Chiropractor determine what may be causing your complaints. By signing below, you have authorized the performance of a consultation and examination.
