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  • New Patient Intake Packet

    Para Español, seleccione del menú desplegable en la esquina superior derecha.

    Đối với tiếng Việt vui lòng chọn từ menu thả xuống ở góc trên bên phải.

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    對於中文,請從右上角的下拉清單中選擇。

    हिंदी के लिए, कृपया ऊपरी दाएं कोने में ड्रॉप डाउन से चयन करें।

    ਪੰਜਾਬੀ ਲਈ ਕਿਰਪਾ ਕਰਕੇ ਉੱਪਰ ਸੱਜੇ ਕੋਨੇ ਵਿੱਚ ਡ੍ਰੌਪ ਡਾਊਨ ਵਿੱਚੋਂ ਚੁਣੋ।

    انگریزی کے لیے، براہ کرم اوپری دائیں کونے میں ڈراپ ڈاؤن سے منتخب کریں۔

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  • No-Show Policy

    Failing to appear for a scheduled appointment may result in immediate discharge from our care and you will not be able to make another appointment with our office. Failing to give 24-hours notice when requesting to reschedule will be considered a no-show. We truly appreciate your understanding.

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  • Financial Disclosure Notice Acknowledgement

    We feel it is important for our patients to have an understanding of our financial policies and how they may be affected by them. Please ask questions regarding this document  before you leave the office today. We are more than happy to assist you!

    PROOF OF INSURANCE: Your insurance card(s) and a picture ID should be brought to each appointment. It is your responsibility to inform the front desk of any changes in  address, phone number or employment and when your insurance plan changes so that  the correct plan is billed for your visit. Failure to provide requested information in a  timely manner will result in the claim(s) becoming the patient's responsibility. It is also your responsibility to know what your benefits are and if we are a participating  provider on your plan.

    CONTRACTED INSURANCE: If we are contracted with your insurance company, we  must follow our contract and their requirements. If you have a copay, coinsurance or a  deductible, you must pay that at the time of service. It is the insurance company that  makes the final determination of your eligibility. It is our obligation under many of our  contracts to report patients who repeatedly refuse to pay copays, coinsurance and deductibles at the time of service or who repeatedly “no show” for appointments. If you are reported, you could possibly lose your health care benefits. Contact your  employer’s human resource department for further clarification of your benefits and  obligations. If your insurance requires a referral and/or prior authorization, you are  responsible for making sure you have that authorization prior to seeing a specialist. 

    NON-CONTRACTED INSURANCE: Your insurance is a contract between you and your  insurance company. We are not a party to that contract. Using an out-of-network  provider will generally result in a greater out of pocket cost. We will bill your primary  insurance company as a courtesy to you and you agree to pay any portion of the  charges not covered by insurance. If your insurance requires a referral or prior  authorization, you are responsible for obtaining it.

    WORKERS COMPENSATION/MOTOR VEHICLE ACCIDENTS: Please note that we cannot treat for worker’s comp injuries; contact your employer for further instruction. If you have been involved in a motor vehicle accident, we can treat you, however, we  cannot bill a third party for the charges. You will be responsible for payment in full and  we will provide you with the information necessary to file on your own.

    PAYMENT OPTIONS: We accept cash, money orders, personal checks, debit, and  credit cards. We do not accept temporary or post-dated checks. Checks presented are  electronically converted to an ACH debit. There is a $25 fee for all returned checks.

    REQUIRED PAYMENTS: Patients without insurance, as well as those who have  insurance but are seen for non-covered services, will be expected to pay in full at the  time of service. Copays, coinsurance and deductibles are due at the time of your visit.

    SECONDARY INSURANCE: Our office does not file with secondary insurances unless required by law. If you do not have a government regulated plan, you will be expected  to pay your primary insurance’s required copayments, coinsurance or deductibles at the time of service.

    FEES: No Show Fees - $25 for missed physicals, well exams or surgical appointments,  and $15 for all other types of missed appointments. FMLA or Disability paperwork:  $25.00 fee due at pick-up of the completed paperwork. Medical Records: One copy  provided per year at no cost. Additional copies are $25.00 for the first 20 pages and  $.15 for every page thereafter, plus postage.

    MONTHLY STATEMENTS: If you have a balance on your account, we will send you a  monthly statement. Unless other arrangements have been made in writing, the balance on your statement is due and payable when the statement is issued, and is past due if  not paid by the end of the month.

    PATIENT RESPONSIBILITY: If you receive a bill after your share has been collected  at checkout, it could be due to several things, including incorrectly quoted benefits or  claim processing by your insurance company. If an explanation of benefits is received  from your insurance company showing a difference in patient responsibility than what  was collected in our office, we will adjust your account accordingly. Please note that  payment at the time of service does not equal payment in full. If you feel your claim  may have been processed incorrectly, please call your insurance company.

    PAST DUE ACCOUNTS: We are a member of the American Credit Bureau. If your  account becomes past due, we will take necessary steps to collect this debt. If your  account is referred to a collection agency, you agree to pay all of the collection costs  which are incurred. Failure to meet your financial obligations may also result in  termination (upon 30 day notice) from treatment by our doctors.

    WAIVER OF CONFIDENTIALITY: You understand if this account is forwarded to a  collection agency and your past due status is reported to a credit reporting agency, the  fact that you received treatment at our office may become a matter of public record.

    DIVORCE: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or  separation, the parent authorizing treatment for a child will be the parent responsible  for those subsequent charges. If the divorce decree requires the other parent to pay all  or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

    EFFECTIVE DATE: Once you have signed the acknowledgment for this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

    I have read the Financial Disclosure Notice provided to me and understand my financial obligations. I agree to pay the amounts required of me for any fees or  services incurred at Elevate (Elevate HC Texas, PLLC). I am over 18 years of age or I am the parent or guardian of the patient. I give permission for Elevate (Elevate  HC Texas, PLLC) to bill my insurance (if applicable) and release information to my insurance, if necessary, for payment of claims.

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  • Notice of Privacy Practices Acknowledgement

    This Notice of Privacy Practices tells you about the ways we may use and disclose your protected health information and your rights and our obligations regarding the use and disclosure of your medical information.

    1. OUR OBLIGATIONS.
      We are required by law to:
      * Maintain the privacy of your medical information, to the extent required by state and federal law;
      *Give you this Notice explaining our legal duties and privacy practices with respect to medical information about you;
      *Notify affected individuals following a breach of unsecured medical information under federal law; and
      *Follow the terms of the version of this Notice that is currently in effect.
    2. CHANGES TO THIS NOTICE.
      We reserve the right to change this Notice at any time, along with our privacy policies and practices. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well, as any information we receive in the future. We will keep a copy of the current notice posted in our office, and a copy will be available at each appointment.
    3. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.
      The following categories describe the different reasons that we typically use and disclose medical information. These categories are intended to be general descriptions only, and not a list of every instance in which we may use or  disclose your medical information. Please understand that for these  categories, the law generally does not require us to get your authorization in  order for us to use or disclose your medical information.
      *Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are  involved in providing the care you need. For example, we may share your  medical information with other physicians or other health care providers who  will provide services that we do not provide. Or we may share this  information with a pharmacist who needs it to dispense a prescription to you,  or a laboratory that performs a test. We may also disclose medical  information to members of your family or others who can help you when you are sick or injured, or after you die.
      *Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan  the information it requires before it will pay us. We may also disclose  information to other health care providers to assist them in obtaining  payment for services they have provided to you. If, however, you pay for an  item or service in full, out of pocket and request that we not disclose to your  health plan the medical information solely relating to that item or service, as  described more fully in Section V of this Notice, we will follow that restriction  on disclosure unless otherwise required by law.
      *Health care operations. We may use and disclose medical information  about you to operate this medical practice. For example, we may use and  disclose this information to review and improve the quality of care we  provide, or the competence and qualifications of our professional staff. We  may also use and disclose this information as necessary for medical reviews,  legal services and audits, including fraud and abuse detection and compliance  programs and business planning and management.
      *Appointment Reminders and Health Related Benefits and Services. We may use and disclose medical information to contact and remind you  about appointments. If you are not available, we may leave this information  on your voicemail or in a message left with the person answering the phone.  We may use and disclose medical information to tell you about health-related  benefits or services that we believe may be of interest to you.
      *Business Associates. We may share your medical information with our “business associates”. When these services are contracted, we may disclose  your medical information to our business associate so that they can perform  the job we have asked them to do. To protect your medical information,  however, we require the business associate to appropriately safeguard your  information.
      *Notification and Communication with Family. We may disclose your health information to notify or assist in notifying a family member, your  personal representative or another person responsible for your care about  your location, your general condition or, unless you had instructed us  otherwise, in the event of your death. In the event of a disaster, we may  disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is  involved with your care or helps pay for your care. If you are able and  available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a  disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or  object, our health professionals will use their best judgment in  communication with your family and others.
      *Marketing. Provided we do not receive any payment for making these  communications, we may contact you to give you information about products  or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers  or settings of care that may be of interest to you. We may similarly describe  products or services provided by this practice and tell you which health plans  this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease  management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase  a product or service when we see you, for which we may be paid. Finally, we  may receive compensation which covers our cost of reminding you to take  and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other  marketing communications without your prior written authorization. The  authorization will disclose whether we receive any compensation for any  marketing activity you authorize, and we will stop any future marketing  activity to the extent you revoke that authorization.
      *Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that  we will receive compensation for your health information if you authorize us  to sell it, and we will stop any future sales of your information to the extent  that you revoke that authorization.
      *Required by Law. As required by law, we will use and disclose your health  information, but we will limit our use or disclosure to the 8 relevant  requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to  law enforcement officials, we will further comply with the requirement set  forth below concerning those activities.
      *Public Health. We may, and are sometimes required by law, to disclose  your health information to public health authorities for purposes related to:  preventing or controlling disease, injury or disability; reporting child, elder or  dependent adult abuse or neglect; reporting domestic violence; reporting to  the Food and Drug Administration problems with products and reactions to  medications; and reporting disease or infection exposure. When we report  suspected elder or dependent adult abuse or domestic violence, we will  inform you or your personal representative promptly unless in our best  professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we  believe is responsible for the abuse or harm.
      *Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the  course of audits, investigations, inspections, licensure and other proceedings,  subject to the limitations imposed by law.
      *Judicial and Administrative Proceedings. We may, and are sometimes  required by law, to disclose your health information in the course of any  administrative or judicial proceeding to the extent expressly authorized by a  court or administrative order. We may also disclose information about you in  response to a subpoena, discovery request or other lawful process if  reasonable efforts have been made to notify you of the request and you have  not objected, or if your objections have been resolved by a court or  administrative order.
      *Law Enforcement. We may, and are sometimes required by law, to  disclose your health information to a law enforcement official for purposes  such as identifying or locating a suspect, fugitive, material witness or missing  person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
      *Coroners. We may, and are often required by law, to disclose your health  information to coroners in connection with their investigations of deaths.
      Organ or Tissue Donation. We may disclose your health information to  organizations involved in procuring, banking or transplanting organs and  tissues.
      *Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or  the general public.
      *Proof of Immunization. We will disclose proof of immunization to a school  that is required to have it before admitting a student where you have  agreed, formally or informally, to the disclosure on behalf of yourself or your  dependent.
      *Specialized Government Functions. We may disclose your health  information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their  lawful custody.
      *Change of Ownership. In the event that this medical practice is sold or  merged with another organization, your health information/record will  become the property of the new owner, although you will maintain the right  to request that copies of your health information be transferred to another physician or medical group.
      *Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us  with a current e-mail address, we may use e-mail to communicate  information related to the breach. In some circumstances our business  associate may provide the notification. We may also provide notification by  other methods as appropriate.
      *Electronic Disclosures of Medical Information. Under Texas law, we are required to provide notice to you if your medical information is subject to  electronic disclosure. This Notice serves as general notice that we may  disclose your medical information electronically for treatment, payment or  health care operations or as otherwise authorized or required by state or  federal law.
      *Psychotherapy Notes. We will not use or disclose your psychotherapy  notes without your prior written authorization except for the following: 1) use by the originator of the notes for your treatment, 2) for training our staff,  students and other trainees, 3) to defend ourselves if you sue us or bring  some other legal proceeding, 4) if the law requires us to disclose the  information to you or the Secretary of HHS or for some other reason, 5) in  response to health oversight activities concerning your psychotherapist, 6) to  avert a serious and imminent threat to health or safety, or 7) to the coroner  or medical examiner after you die. To the extent you revoke an authorization  to use or disclose your psychotherapy notes, we will stop using or disclosing  these notes.
      *Research. We may disclose your health information to researchers  conducting research with respect to which your written authorization is not  required as approved by an Institutional Review Board or privacy board, in  compliance with governing law.
      *Fundraising. We may use or disclose your demographic information in  order to contact you for our fundraising activities. For example, we may use  the dates that you received treatment, the department of service, your  treating physician, outcome information and health insurance status to  identify individuals that may be interested in participating in fundraising  activities. If you do not want to receive these materials, notify the Privacy  Officer and we will stop any further fundraising communications. Similarly,  you should notify the Privacy Officer if you decide you want to start receiving  these solicitations again.
    4. WHEN THIS MEDICAL PRACTICE MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION
      Except as described in this Notice of Privacy Practices, this medical practice  will, consistent with its legal obligations, not use or disclose health  information which identifies you without your written authorization. If you do  authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
    5. YOUR HEALTH INFORMATION RIGHTS
      *Right to Request Special Privacy Protections. You have the right to  request restrictions on certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what  limitations on our use or disclosure of that information you wish to have  imposed. We reserve the right to accept or reject any other request, and will  notify you of our decision.
      However, If you pay or another person (other than a health plan) pays on your behalf for an item or service in full, out of pocket, and you request that  we not disclose the medical information relating solely to that item or service  to a health plan for the purposes of payment or health care operations, then  we will be obligated to abide by that request for the restriction unless the  disclosure is otherwise required by law. You should be aware that such  restrictions may have unintended consequences, particularly if other  providers need to know that information (such as a pharmacy filling a  prescription). It will be your obligation to notify any such other providers of  the 9 restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of  pocket (and which would not be subject to the restriction).
      *Right to Request Confidential Communications. You have the right to  request that you receive your health information in a specific way or at a  specific location. For example, you may ask that we send information to a  particular e-mail account or to your work address. We will comply with all  reasonable requests submitted in writing which specify how or where you  wish to receive these communications.
      *Right to Inspect and Copy. You have the right to inspect and copy your  health information, with limited exceptions. To access your medical  information, you must submit a written request detailing what information  you want access to, whether you want to inspect it or get a copy of it, and if  you want a copy, your preferred form and format. We will provide copies in  your requested form and format if it is readily producible, or we will provide  you with an alternative format you find acceptable, or if we can’t agree and  we maintain the record in an electronic format, your choice of a readable  electronic or hardcopy format. We will also send a copy to any other person  you designate in writing. We will charge a reasonable fee which covers our  costs for labor, supplies, postage, and if requested and agreed to in advance,  the cost of preparing an explanation or summary. We may deny your request  under limited circumstances. If we deny your request to access your child's  records or the records of an incapacitated adult you are representing because  we believe allowing access would be reasonably likely to cause  substantial harm to the patient, you will have a right to appeal our decision.  If we deny your request to access your psychotherapy notes, you will have  the right to have them transferred to another mental health professional.
      *Right to Amend or Supplement. You have a right to request that we  amend your health information that you believe is incorrect or incomplete.  You must make a request to amend in writing, and include the reasons you  believe the information is inaccurate or incomplete. We are not required to  change your health information, and will provide you with information about  this medical practice's denial and how you can disagree with the denial. We  may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to  inspect or copy the information at issue, or if the information is accurate and  complete as is. If we deny your request, you may submit a written statement  of your disagreement with that decision, and we may, in turn, prepare a  written rebuttal. All information related to any request to amend will be  maintained and disclosed in conjunction with any subsequent disclosure of  the disputed information.
      *Right to an Accounting of Disclosures. You have a right to receive an  accounting of disclosures of your health information made by this medical  practice, except that this medical practice does not have to account for the  disclosures provided to you or pursuant to your written authorization, or as  described in paragraphs 1 (treatment), 2 (payment), 3 (health care  operations), 6 (notification and communication with family) and 18  (specialized government functions) of Section III of this Notice of Privacy  Practices or disclosures for purposes of research or public health which  exclude direct patient identifiers, or which are incident to a use or disclosure  otherwise permitted or authorized by law, or the disclosures to a health  oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that  providing this accounting would be reasonably likely to impede their activities.
      *Right to a Paper or Electronic Copy of this Notice. You have a right to  notice of our legal duties and privacy practices with respect to your health  information, including a right to a paper copy of this Notice of Privacy  Practices, even if you have previously requested its receipt by e-mail.
    6. COMPLAINTS
      Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to:

      Privacy Officer
      Elevate Health Clinics
      712 N Washington Ave, Suite 200, Dallas, TX 75246
      855-435-3828

      If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:

      The U.S. Department of Health & Human Services
      Office of Civil Rights
      200 Independence Avenue, S.W.
      Washington, D.C. 20201 (202) 619-0257
      Toll Free: 1-877-696-6775
  • By signing below, you acknowledge that you have received the Notice of Privacy Practices and you consent to the use and disclosure of your medical information except as expressly stated below. You understand that i (Elevate HC Texas, PLLC) has the right to change its Notice of Privacy Practices and that you may contact Elevate (Elevate HC Texas, PLLC) at any time if you have any questions.

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  • Telemedicine Consent

    Telemedicine involves the use of electronic communications to enable  health care providers at different locations to share individual patient  medical information for the purpose of improving patient care.
    Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy,  follow-up and/or education, and may include any of the following:

    • Patient medical records
    • Medical images
    • Live two-way audio and video
    • Output data from medical devices and sound and video files

    Electronic systems used will incorporate network and software security  protocols to protect the confidentiality of patient identification and  imaging data and will include measures to safeguard the data and to  ensure its integrity against intentional or unintentional corruption.

    Expected Benefits

    • Improved access to medical care by enabling a patient to remain in his/her physician's office or at a remote site while the physician obtains test results  and consults from healthcare practitioners at distant/other sites.
    • More efficient medical evaluation and management.
    • Obtaining expertise of a distant specialist.

    Possible Risks

    As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

    • In rare cases, information transmitted may not be sufficient (e.g. poor  resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
    • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
    • In very rare instances, security protocols could fail, causing a breach of  privacy of personal medical information.
    • In rare cases, a lack of access to complete medical records may result in  adverse drug interactions or allergic reactions or other judgment errors.

    By signing this form, I understand the following:

    • I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
    • I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
    • I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
    • I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
    • I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be  located in other areas, including out of state.
    • I understand that it is my duty to inform my physician of electronic  interactions regarding my care that I may have with other healthcare  providers.
    • I understand that I may expect the anticipated benefits from the use of  telemedicine in my care, but that no results can be guaranteed or assured.
  • Patient Confidentiality andTreatment of Private Medical Information

  • Protected Health Information Disclosure Authorization

    This form will authorize the below facility to provide a copy or summary of my medical records to Elevate Health Clinics as indicated on this authorization:

  • The above information may be released to:
    Elevate Health Clinics
    712 N Washington Ave, Dallas, TX 75246
    Phone: 855.435.3828 Fax: 214.377.5022

  • I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise required by law. I understand that if  the organization authorized to receive the information is not a health plan or  healthcare provider or other entity considered a covered entity under HIPAA, the  released information may no longer be protected by federal privacy regulations. I  further understand that information disclosed pursuant to this authorization may be  re-disclosed by the parties listed above and no longer protected. I have the  right to revoke this authorization in writing except to the point that action has  already been taken in reliance upon the authorization. I also understand that  treatment or payment cannot be conditioned on the authorization. 

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  • Irrevocable Provider/Patient Assignment, Lien, Power of Attorney, Document/Records Release, and Payment Agreement

     

    THIS IRREVOCABLE, NON-RESCINDABLE, AGREEMENT and ASSIGNMENT OF LIEN INTEREST/BENEFITS is entered into this date by and between the above named patient, hereinafter called "Patient", and Elevate Health Clinics, hereinafter called  “Provider”. 

    WHEREAS, Patient desires to receive health care services from Provider and requests  that Provider provide such services, but defer payment on the part of Patient for such  services until Patient secures his/her Insurance settlement proceeds. In consideration  of Provider's willingness to agree to such terms Patient does hereby: irrevocably g rant a medical lien to the Provider and assign the following rights and benefits to Provider  as the legal consideration and inducement to cause Provider to forego its legal right to  require payment upon provision of services and wait for the payment of such benefits  from Patient until such time that Patient’s legal claims against at-fault party is resolved either through litigation and/or negotiations, It Is hereby agreed:

    SECTION 1. Patient hereby irrevocably acknowledges financial responsibility for all  reasonable and necessary medical services provided to patient by Provider as  consideration for such Provider services. If at any time, the Patient is not represented  by a licensed attorney in a claim against the at-fault party or an insurance carrier, then the Patient irrevocably assigns to Provider any and all legal claims against the party or  parties that gave rise to Patient's claims for damages for which Provider has been  engaged to provide healthcare services, including Patient's legal entitlement to  monetary proceeds due to be paid by or through any health insurance, liability, PIP or  medical payment Insurance coverage that is/are maintained by Patient or under which  Patient derives some legal entitlement arising as a result of the injuries suffered from  an automobile accident, for which Provider has rendered the above described health  care services. Patient irrevocably grants, conveys and assigns to Provider a monetary  Interest and lien upon the proceeds of Patient's personal injury claim against the  person(s) or party(les) responsible for Patient's Injuries in the exact amount necessary to pay the reasonable charges for the necessary treatment to alleviate Patient's  injuries rendered by Provider. Patient's lien interest granted and conveyed to Provider  shall extend from any automobile medical payment coverage maintained by Patient or  any person under whose policy of Insurance Patient may have a lawful right of  recovery, (ii) any and all benefits, claims and/or causes of action, payable by or under  any third party liability insurance coverage to which Patient may have a right of  recovery due to the services rendered by Provider, and (iii) a "common law lien  Interest" in, and all contractual rights and claims to, any and all insurance proceeds to  which Patient has or maintains a legal entitlement, to be paid by or from any Insurance company, health care benefit plan, or any other party contractually liable for payment  of all or any portion of the charges for health care services rendered by Provider to the Patient as a result of the injuries sustained by Patient. This irrevocable assignment of  benefits, conveyance and assignment of lien interest and conveyance and assignment  of contractual rights to and for those charges attributable to Provider's health care  services shall extend to, but not be limited to, Provider's entitlement to any and all  claims, causes of action and insurance proceeds remitted as a result of any insurance  claim for damages by the Patient which has given rise to the above referenced health  care services provider by Provider, as recognized under the holdings of Ford Motor  Credit Co, v, Allstate, 2 S.W. 3d 810 (Mo^pp.W.D. 1999) and Marvin's Midtown  Chiropractic Clinic, LLCv. State Farm Mutual Automobile Insurance Company. 142 S.W.  3d 751 (Mo.App, W.D. 2004). Patient consents to Provider sending their file to a potential new legal representative in the case of dissolution of their current legal  representation.

    This irrevocable assignment of benefits and lien Interest shall extend to the total  amount of reasonable and customary charges incurred by Patient for services rendered by Provider. Patient agrees that full payment for all services rendered by Provider is  due upon receipt of said services and Patient accepts full financial responsibility for  payment for such services. Patient acknowledges that Patient is ultimately financially  responsible for the payment of all reasonable and necessary medical services that  Patient receives from Provider regardless whether any portion of those fees and  charges due to be paid by Patient to Provider are paid through insurance proceeds to  which Patient has asserted a claim. Patient acknowledges that Provider's acceptance of  Patient's irrevocable assignment of benefits and lien interest is a convenience to  Patient, and that Provider may revoke this assignment and lien interest at any time. 

    SECTION 2. If at any time, the Patient is not represented by a licensed attorney in a  claim a gainst the at-fault party or an insurance carrier, then the Patient hereby grants  and conveys to Provider a limited power of attorney to accept any payment provided In Patient's name by any Insurer as consideration for the services provided by Provider to Patient and Patient does grant and convey Provider with a limited power of attorney to sign patient's name to any such insurance check, bank draft or other form of  negotiable Instrument remitted by any person or insurer as consideration or  compensation for the injuries sustained by Patient and/or the health care services  rendered to Patient by Provider.

    SECTION 3. If at any time, the Patient is not represented by a licensed attorney  in a claim a gainst the at-fault party or an insurance carrier, then the Patient  hereby Irrevocably directs all Insurers, Page 1 health care plans, legal counsel,  and other persons or parties responsible for the payment, co-payment or other  obligation for Patient's health care costs arising from injuries sustained by Patient  for which the above referenced services have been provided by Provider, to remit  and/or make all monetary payments remitted as consideration, in whole or in part, for those health care services rendered by Provider for and on behalf of Patient,  directly to Provider. Patient further directs that any lawyer or representative  employed by Patient to represent Patient in any action for which the above  referenced services have been rendered by Provider, insurer or third party, shall  be, and is hereby, irrevocably Instructed and required to withhold from any  monetary distribution to Patient, Patient's lawyer and/or any other person or party  asserting any monetary interest against any proceeds to which Patient may  awarded, the full amount of Patient's outstanding and unpaid account due and  owing to Provider out of any private party settlement proceeds, insurance  settlement proceeds of whatever nature (liability, PIP, etc.), and/or any court  verdict and remit payment of the dollar amount of Patient's unpaid and  outstanding account with Provider, directly to Provider immediately upon receipt of  same. This directive made by the Patient to the Patient's lawyer is to be deemed  irrevocable and non-rescindable and shall extend to and include any PIP or medical payment benefits recovered by or on the Patient's behalf of the Patient or Patient's  lawyer. 

    SECTION 4. If at any time, the Patient is not represented by a licensed attorney  in a claim a gainst the at-fault party or an insurance carrier, then the Patient  willfully and voluntarily makes and appoints Provider, through its duly appointed  representative, residing in the City of Dallas, Dallas County, Texas, as Patient's lawful Attorney-In-Fact for purposes of receiving and directing  disbursement of the above described payments or settlement proceeds to be paid  to Patient, or on Patient's behalf, as compensation for those for the health care  services rendered by Provider, and the resultant payment obligations owed by  Patient to Provider as a result of same. Patient hereby delegates and conveys to  Provider those rights and powers of substitution on Patient's behalf, to ask,  demand, sue for, collect, endorse, sign, and receive such monetary proceeds, in  Patient's name, to PIP insurance, other health benefits, and third party claims relating to services rendered to Patient by Provider. Although Provider is  granted such special powers contained herein. Provider is not obligated or  compelled to exercise such powers but may do so at Provider's discretion. Patient  agrees to cooperate with Provider to request and receive from any insurer,  employer, or other third party payer any and all information or supporting  documentation concerning or touching upon the handling, calculation, processing,  or payment of any claims arising from services rendered to Patient by Provider. 

    SECTION 5. To the extent that Patient has lawful authority, Patient agrees to toll  any applicable statute of limitations that may at any time interfere with Provider's  right to collect for services rendered to Patient as well as any other statutory obligation on the part of Provider to bill for or seek collection from any  other source of insurance proceeds until such time that Patients claim against the  at-fault party or insurance carrier has been resolved through litigation or  negotiations . Patient agrees that in the event Patient or Patient's authorized  representative, including legal counsel, receives any check, draft, or other  payment subject to this Agreement, Patient and Patient's authorized representative shall be deemed to serve in a fiduciary capacity to Provider, for the benefit of  Provider, with full obligation to immediately deliver said check(s), draft(s), or payment(s) to Provider. Provider agrees to apply the proceeds from said  check(s), draft(s), or payment(s) to Patient's debt for services rendered and to the extent that (a) such services are reasonable and necessary; and (b) charges are  reasonable, usual, and customary.

    SECTION 6. Patient hereby irrevocable consents to, and authorizes, his  lawyer/legal counsel to release to Provider, upon request by Provider, any and all  records or documentation pertaining to Provider's insurance claims, legal claims,  pending causes of action, or otherwise pertaining to the expense or charge for any  service rendered by Provider for Patient's benefit. 

    SECTION 7. If at any time, the Patient is not represented by a licensed attorney  in a claim a gainst the at-fault party or an insurance carrier, then the Patient  irrevocably agrees and consents to Provider's submission of a copy of this  Agreement and any other claim for payment of insurance proceeds to any and all insurance carrier(s) against whom Patient Is, or may, assert or maintain any  claim for damages and reimbursement for the cost for those services provided by  Provider, Including, but not limited to, any insurance coverage for Medical  Payments, Personal Injury Protection or third party liability insurance payments. A  copy of this document shall be as binding as the document bearing original  signatures.

    SECTION 8. This agreement supersedes and replaces any prior Assignment of  Benefits signed between the Provider and the Patient. In the event that any  Section or provision of this Agreement is determined to be legally void, Invalid, or  unenforceable, all other Sections and provisions of this Agreement shall remain in  full force and effect. Patient may not revoke the assignments and agreements  contained in this document without the express written consent of Provider. 

    IN WITNESS WHEREOF, this agreement has been entered Into the day and year  set forth below.

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  • I confirm that I have provided a complete and accurate list of all medications I am currently taking in the form above. I understand that failure to disclose all medications—including name, dosage and frequency—may prevent my provider from prescribing additional medications due to the risk of potential drug interactions.

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