NAME
SS#
ADDRESS
CITY
STATE
ZIP
HOME PHONE
WORK PHONE
BEEPER/CELL PHONE #
E-MAIL
BIRTHDATE
SEX:
MALE
FEMALE
MARITAL STATUS
EMERGENCY CONTACT
PHONE #
MOTOR VEHICLE INSURANCE CARRIER:
PRIMARY INSURANCE CO.
INSURANCE ADDRESS
TELEPHONE #
DATE OF ACCIDENT:
Claim no:
Pol#:
ADJUSTER NAME:
ADJ PHONE:
Policy holder:
SELF
SPOUSE
PARENT
OTHER
DATE OF ACCIDENT
COUNTY/LOCATION OF ACCIDENT:
ATTORNEY NAME:
PHONE:
HEALTH INSURANCE INFO:
INS CO:
INSURANCE ADDRESS
TELEPHONE #
ID#
GROUP #
SUBSCRIBER
RELATIONSHIP
BIRTHDATE
SS #
ACKNOWLEDGEMENTS AND ASSIGNMENTS
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE:
I________________________________________ understand that in the course of providing care to me that Kenneth Zahl, MD, or PainDoctor, LLC will receive, create, maintain and disclose information about me for the purpose of the Practice’s and other health provider’s provision of treatment, securing payment from me, an insurer, other third-party payer or responsible party, and/or in connection with the health care operations of the Practice(s) and/or the operations other health providers who have treated me and as otherwise required or permitted by State and/or Federal Law. I understand that a further description of these anticipated uses and disclosures of my health information appears in the Practice’s Notice of Privacy Practices.
Except for genetic information, I agree to the sharing, utilization, examination and disclosure of any of my health information, including but not limited to known or suspected HIV/AIDS infection, mental health records, communicable diseases, substance abuse and/or treatment, if applicable, as is reasonably necessary by the Practice, its employees and other members of its workforce for the limited purpose of rendering treatment, securing payment for treatment rendered and conducting the Practice’s operations. I further agree to the disclosure by the Practice of such information, as is reasonably necessary, to other health providers involved in my treatment and their employees and other members of their workforce for treatment, payment and health operations, to any private or governmental insurer, including Medicaid and Medicare and its intermediaries and agents, other third-party payers, or other financially responsible party for the purpose of determining benefits and securing payment, and as otherwise permitted by State and/or Federal law.
This consent may be revoked at any time but, only to the extent that the Practice has not acted in reliance on it. If not previously revoked, this consent will remain valid as long as I am a patient of the Practice and for such period of time thereafter as is reasonably necessary to serve the purpose for which it was given; namely, the provision of treatment, securing payment for services rendered and conducting health operation
BILLING POLICIES
I further expressly agree and acknowledge that my signature on this document authorized Kenneth Zahl, MD, or PainDoctor, LLC or their employees to submit claims for services rendered without obtaining my signature on each and every claim to be submitted for myself and/or dependents and that I will be bound by this signature as though the undersigned had personally signed the particular claim.
I am aware that for either practice to bill to my insurance carrier on my behalf is a courtesy being extended to me and is NOT required by law. I further agree and fully understand that I am legally bound to furnish the checks paid to me by my carrier for the services I am receiving from this practice.
I also agree and fully understand that as a non-participating physician, Dr. Zahl is not bound or legally obligated to accept the payment from my insurance company as payment in full for the services I am receiving, and I will receive a balance bill for the amounts not paid by my carrier. I hereby authorize the above named insurance company/companies to assign directly all benefits payable on my behalf.
I hereby authorize the above named insurance company/companies to assign directly all benefits payable. I make this an irrevocable assignment of benefits. I understand that any insurance checks issued belong to Kenneth Zahl, MD, or PainDoctor, LLC for services rendered and I agree to endorse them over should I receive them or otherwise repay any amounts paid to me. Failure to do so would be a crime under New Jersey law
I(we) am (are) aware that if payment is not made within a reasonable amount of time by the insurance carrier(s), that the and the matter is submitted to a collection agency/attorney, I (we) will be responsible for payment of all costs associated with that collection activity, including but not limited to reasonable attorney’s fee’s, and court costs.
I fully understand that once the account is being past due the practice reserves the right to begin adding interest at 1% per month simple interest, and if sent to collection, I (we) will be responsible for costs for collection agents and/or reasonable attorneys fees and/or costs of litigation.
Patient SIGNATURE ________________________DATE____________________
Insured’s SIGNATURE ______________________ if different ________________
IF THIS IS RELATED TO AN AUTO ACCIDENT IN NEW JERSEY PLEASE READ AND SIGN THE NEXT PAGE
ASSIGNMENT OF BENEFITS & LTD. POWER OF ATTORNEY
I irrevocably assign to you, my medical provider, all of my rights and benefits under my insurance contract for payment for services rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically includes filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably authorize you to retain an attorney of your choice on my behalf for collection of your bills I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize you to act on my behalf. I consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to the “benefit denial appeals process” set forth in the NJ Administrative Code.
In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid, I execute this limited/special power ofattorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case in my name including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against that carrier in my name or in your name as a medical provider rendering services to me and designate your collection attorney as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter, and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me.
I authorize you and or your attorney to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to release all such information to you about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my physical condition.
Dated:
________________________________
Patient Signature
_________________________________
Witnessed
PLEASE DESCRIBE YOUR ACCIDENT IN DETAIL
(please choose one)
1. Were you driving the vehicle?
Yes
No
2. Were you a passenger?
Yes
No
3. Were you wearing a seatbelt?
Yes
No
4. What type of vehicle were you in? Econocar Sedan SUV Truck
5. Did the police respond?
Yes
No
6. Were you taken to the Emergency room?
Yes
No
7. If so, what hospital?
8. How were you transported there?
Ambulance
other vehicle
9. Were X-rays taken?
Yes
No
10. Was your insurance company notified?
Yes
No
11. Did you see your primary care physician?
Yes
No
Please list other physicians you have seen as a result of injuries you sustained in this accident.
PLEASE DESCRIBE IN DETAIL HOW YOUR ACCIDENT HAPPENED
SIGNATURE: ____________________________
DATE:_____________________ |