EMC INTAKE
Auto/Injury Medical Intake
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Consents
I, the undersigned patient/insured, knowingly, voluntarily and intentionally irrevocably assign the rights and benefits of my automobile Insurance, known as Personal Injury Protection (hereinafter PIP), Uninsured Motorist, and MedicalPayments policy of insurance to the above health care provider. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time of service. I understand this document will allow the provider to file suit against an insurer for payment of the insurance benefits or an explanation of benefits and to seek 627.428 damages from the insurer. This assignment of benefits includes transportation, medications, supplies, overdue interest and any potential claim for common law or statutory bad faith/unfair claims handling. If the insurer disputes the validity of this assignment of benefits then the insurer is instructed to notify the provider in writing within five days of receipt of this document. Failure to inform the provider shall result in a waiver by the insurer to contest the validity of this document. The undersigned directs the insurer to pay the health care provider the maximum amount directly without any reduction and without including the patient's name on the check. To the extent the PIP insurer contends there is a material misrepresentation on the application for insurance resulting in the policy of insurance is declared voided, rescinded, or canceled, I as the named insured under said policy of insurance, hereby assign the right to receive the premiums paid for my PIP insurance to this provider and to file suit for recovery of the premiums. The insurer is directed to issue such a refund check payable to this provider only. Should the medical bills not exceed the premium refund, then the provider is directed to mail the patient/named insured a check which represents the difference between the medical bills and the premiums paid.
LIEN: I, the undersigned patient, guarantee full payment to the provider that is providing the services. I agree that I will remain personally responsible for unpaid charges as a result of any deductible, co-payment, and treatment after benefits are exhausted and/or for any other treatment/ service that remain unpaid. Furthermore, I grant the provider a lien against any recovery, which I may have against any tortfeasor, responsible party, or any responsible insurance carrier. I direct my attorney to withhold any funds I receive from any settlement to pay for any outstanding balance to the provider I agree to and instruct my attorney to promptly advise the provider who conducts and bills this exam, of any settlement as a result of the injuries sustained in the (DATE OF CAR ACCIDENT DOCUMENTED ABOVE) motor vehicle accident, or motorcycle accident. Additionally I agree and instruct my attorney that I will not accept any settlement check until the remaining balance is resolved with the provider who is performing this examination.
DISPUTES: The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim that contain or are accompanied by language releasing the insurer or it's insured patient from liability unless there has been a prior written settlement agreed to by the health provider (specifically the office manager) and the insurer as to the amount payable under the insurance policy. The insured and provider hereby contests and objects to any reductions or partial payments.Any partial or reduced payment, regardless or the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement, or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bill submitted. If the PIP insurer states it can pay claims at 200% of the Medicare Fee Schedule or any other fee schedule contained within Fla. Stat. 627.736 (2018), the insurer is instructed & directed to provide this provider with a copy of the policy of insurance within 10 days. Any effort by the insurer to pay a disputed debt as full satisfaction must be mailed to the above, after speaking with the office billing manager and mailed to the attention of the office billing manager.See Fla. Stat. 673.3111.
RELEASE OF INFORMATION : I hereby authorize this provider to: furnish an insurer, an insurer's intermediary, the patient's other medical providers, and the patients attorney via mail, fax, or email, with any and all information that may be contained in the medical records, and for my insurance carrier to send insurance coverage information(declaration sheet & policy of insurance) in writing and telephonically to the above-named provider: request from any insurer all explanation of benefits (EOBs) for all provider and non-redacted PIP payout sheets; obtain any written and verbal statements the patient or anyone else provided to the insurer, obtain copies of the entire claim file and all medical records, including but not limited to, documents, reports, scans notes bills, opinions, X-rays, IMEs, and MRIs, from any other medical provider or any insurer. The provider is permitted to produce my medical records to its attorney in connection with any pending lawsuits. The insurer is directed to keep the patient's medical record from this provider private and confidential. The insurer is not authorized to provide these medical records to anyone without the patient's and the provider's prior express written permission. PLEASE NOTE: The insurer is not authorized to release protected health information (PHI) to third party vendors that schedule independent medical examinations or independent medical examination physicians.
DEMAND: Demand is hereby made for the insurer to pay all bills within 30 days without reduction and to mail the latest non-reduced PIP payout sheet ad the insurance coverage declaration sheet, and the insurance policy to the above provider within 15 days, as well as notify the provider pursuant to F.S. 627.736 (6-F) when benefits have been exhausted. The insurer is directed to pay the bill in the order they are received.However, if a bill from this provider and a claim from anyone else is received by the insurer on the same day, the insurer is directed to not apply this provider's bill to the deductible. If a bill from this provider and a claim from anyone else is received by the insurer, on the same day, the insurer is directed to pay this provider first before the policy is exhausted. The insurer is instructed to inform, in writing, the provider of any dispute.
CAUTION: Please read before signing. If you do not completely understand this document, please ask us to explain it to you. If you sign below we will assume you understand and agree to the above. I certify that I have read and agreed to all of the above and was not solicited or promised anything in exchange for receiving health care. I agree that the prices for medical care are reasonable.
I, hereby authorize and direct my insurance company to send all payments to The Provider who conducted this examination and billed this examination and accounting of payouts made under all claims submitted for payment under the above referenced policy relating to the automobile accident occurring on the above referenced date as those payments.
I, name above, hereby give my informed consent for a virtual examination to be conducted by the medical provider listedd on the cliam, and their designated healthcare professionals. I understand that this examination will be conducted remotely using video conferencing technology or other virtual platforms.I acknowledge and understand the following:
1. Purpose of the Virtual Examination: The virtual examination is being conducted to assess my medical condition, provide medical advice, and recommend appropriate treatment options.
2. Nature of the Virtual Examination: The virtual examination will involve a healthcare professional asking me questions about my medical history, symptoms, and current condition. I may be required to provide visual or audio information to aid in the examination. The healthcare professional may also request additional medical records or diagnostic tests to be shared electronically.
3. Benefits and Risks: I understand that the virtual examination offers the convenience of remote healthcare access. However, I acknowledge that there may be limitations to the accuracy and effectiveness of a virtual examination compared to an in-person examination. I understand that there are potential risks associated with the use of technology, such as technical difficulties, privacy breaches, and limitations in the healthcare professional's ability to fully assess my condition.
4. Confidentiality and Privacy: I understand that my personal health information will be handled in accordance with applicable privacy laws and regulations. I consent to the collection, use, and disclosure of my personal health information for the purposes of the virtual examination and subsequent medical care.
5. Alternative Options: I understand that I have the right to decline a virtual examination and request an in-person examination if I believe it is necessary for my medical condition. I have been informed of the potential risks and benefits of both options.
6. Questions and Clarifications: I have had the opportunity to ask questions and have received satisfactory answers regarding the virtual examination, its purpose, and any concerns I may have by signing below, I acknowledge that I have read and understood the contents of this medical consent form.
I voluntarily consent to undergo a virtual examination and authorize the medical provider and their designated healthcare professionals to conduct the examination.
Standard Disclosure and Acknowledgement Form
Personal Injury Protection - Initial Treatment or Service Provided
The undersigned insured person (or guardian of such person) affirms:
1. The services or treatment set forth below were actually rendered. This means that those services have already been provided.
Examination:
2. I have the right and the duty to confirm that the services have already been provided.
3. I was not solicited by any person to seek any services from the medical provider of the services described above.
4. The medical provider has explained the services to me for which payment is being claimed.
5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.
Insured Person (patient receiving treatment or services) or Guardian of Insured Person:
The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:
A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.
B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.
D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.
Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):
