The undersigned patient and/or responsible party, in addition to continuing personal responsibility, and inconsideration of treatment rendered or to be rendered assigns, to the physician/facility named above, the following rights of power and authority.RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to my insurance company, attorney, or insurance adjuster for the purposes of processing my claim or benefits and payment of services rendered to me.IRREVOCABLE ASSIGNMENT OF BENEFITS: You are assigned to 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 services rendered, make demand in my name for payment, and prosecute and receive payment, penalties, interest, court costs, or other legally compensable amounts owed by an insurance company in accordance with article 3.62 of the Texas Insurance Code or other applicable insurance or state statute. I and/or my responsible party further agree to cooperate, provide information, and appear as needed, wherever to assist in the prosecution of said claims for benefits, upon request.DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us you are hereby tendered demand to pay in full for services rendered by the physician/facility named above within 60 days following your receipt of such bill to the extent such bills are payable under the terms of my/our policy for benefits, less than amount which I owe personally which are not payable under the terms of policy. This demand specifically conforms with Article 3.62 and 3.62.1 of the Texas Insurance Code, providing for attorney fees. 12% court costs, and interest form judgment, upon violation. THIRD PARTY LIABILITY: If a patient's treatment for injuries is the result of any third party, then patient(s) grant a lien against any recovery from such third party(s) to the extent of the bills for treatment, in favor of the physician/facility named above.STATUTE OF LIMITATIONS: I/we waive the right to claim any Statute of Limitation regarding claims for services rendered or to be rendered by the physician/facility named above. In addition to reasonable costs of collection, including attorney fees and court costs, if incurred. LIMITED POWER OF ATTORNEY: I/we hereby grant to the physician/facility named above power to endorse my name(s) upon checks, drafts, and other negotiable instruments representing payment from the insurance company representing payment for services rendered by the physician/facility named above. I/we agree that any insurance payment representing an amount in excess of the charge for services rendered will be credited to my/our account or forwarded to my/our address upon request in writing to the physician/facility named above.TERMINATOR OF CARE WAIVER: I/we hereby acknowledge and understand that if I/we do not keep appointment as recommended to me/us by my/our caring Doctor and this Chiropractic office, he/she has full and complete right to terminate responsibility for my care and relinquish any disability granted me/us within a reasonable period of time.NOTE: If, during the course of your care, your insurance company requires you to consult or be examined by any other physician, you must notify us immediately; failure to do so may jeopardize your case.
A PHOTOCOPY OF THIS INSTRUMENT SHALL SERVE AS ORIGINAL
Signature(s) of Patients and/or Responsible Party(s):
State of Texas
Before me this day personally appeared the person(s) whose signature(s) appear above who by me duly sworn upon oath says(s) that the statements set forth above are true and correct. Subscribed and sworn before me the... (please fill in the date below)