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After
printing the document, please fill it out completely.
Bring the completed and
signed document with you to your office visit.
By doing so you’ll be able to
speed up the initial registration process of your office visit.
Weis Chiropractic & Physical Therapy Center
10671 McSwain Drive
Cincinnati, OH 45241
Voice: 513.563.0414 FAX: 513.563.9540
CHIROPRACTIC AUTHORIZATION
RELEASE & EXPLANATION
CONSENT FOR CHIROPRACTIC TREATMENT
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I hereby
request and authorize Dr. __________________________ at Weis Chiropractic & Physical Therapy Center to perform diagnostic tests and render
chiropractic adjustments and other treatment. This
authorization also extends to all other doctors and office staff
members and is intended to include radiographic examination at the
doctor's discretion. |
PATIENT'S OR AUTHORIZED
PERSON'S SIGNATURE
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I
Authorize Payment of Any Medical Benefits from
________________________ to be Paid Directly to This Chiropractic
Clinic for Any Service Rendered to Me. |
AUTHORIZATION AND
ASSIGNMENT
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In
consideration of your undertaking to care for me, I agree to the
following:
- You are authorized to release
any information you deem appropriate concerning my physical
condition to any insurance company, attorney, or adjuster in order
to process any claim for reimbursement of charges incurred.
- I authorize the direct payment
to you of any sum I now or hereafter owe you by my attorney out of
the proceeds of any settlement of my case, and by any insurance
company obligated to make payment to me or you based in whole or
in part upon the charges made for your services.
- In the event any insurance
company obligated by contractual agreement to make payments to me
or to you for the charges made for your services refuses to make
such payment upon demand by you, I hereby assign and transfer to
you the cause of action that exists in my favor against any such
company (the name(s) of which is believed to be correctly set
forth under pertinent data) and authorize you to prosecute said
action either in my name as you see fit and further authorize you
to have been made to collect sums due for the insurance company,
or companies, contractually obligated, you will refrain from
attempts and efforts to collect the amounts owed directly from me.
I understand that whatever amounts you do not collect from
insurance companies' proceeds, whether it be all or part of what
is due, I personally owe you.
- I hereby waive the statue of
limitations on collection regarding my case and care.
- I further agree that this
Authorization and Assignment is irrevocable until all monies owed
are paid in full.
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MEDICAL RECORDS RELEASE
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KNOW ALL
MEN BY THESE PRESENTS: That I, ____________________________ hereby
authorize the release of my medical/chiropractic records or copies
of the same to such parties the doctor may deem necessary as it
relates to my case, and do hereby hold harmless anyone from such
actions. DATE
__________________________
SIGNATURE
__________________________________________________
WITNESS
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