Patient Demographic

Insurance Information

Attorney and Chiropractor Information

Medical Examination Informed Consent

An “Emergency Medical Condition” is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention would reasonably be expected to result in any of the following:
Serious jeopardy to patient health, Serious impairment of bodily function, Serious dysfunction of any bodily organ or part.

Prior to participating in this evaluation, you should be aware of 3 (three) very important points regarding this evaluation

• The purpose of the evaluation is to determine whether or not your injury is an emergency medical condition.
• The results of the evaluation will be disclosed in a report to the referring source, and may be provided to other health care professionals that have been retained for similar purposes.
• The evaluator conducting this assessment has been retained as an independent evaluator and no doctor-patient relationship exists. Therefore, no treatment will be provided.

After you have read the following statement, please sign your name below.

“I understand that the purpose of the appointment is evaluation only. I realize that a traditional doctor-patient relationship will not be established during the course of this evaluation and that no treatment will be undertaken. I further understand that the referring source will receive any report that follows as a result of this evaluation and any further consultations. In signing below, I agree to participate in this evaluation.”

The nature, purpose and process of this Emergency Medical Evaluation have been explained to my satisfaction. I have read the above statement and hereby authorize the evaluator to perform the evaluation.

Assignment Of Benefits, Direction To Pay, Release Of Records, And Authority To Sign

DIRECTION TO PAY: The undersigned patient directs the insurer to pay medical provider directly (i.e. payments to be mailed to and made payable to the medical provider) for services rendered.

The undersigned agrees to comply with all terms and conditions of the policy of insurance at issue, including but not limited to appearing for an independent medical examination and/or sworn statement at the request of the insurer. In the event that the medical provider is required to file a lawsuit against the insurer for payment, the undersigned patient agrees to cooperate with the medical provider’s attorney and the insurer. In the event the subject medical benefits are disputed or reduced for any reason, including but not limited to medical reasonableness and/or necessity; the undersigned patient hereby instructs the insurer to set aside any amount disputed and not pay the disputed amount to anyone including myself or any entity until the dispute is resolved. Further, I hereby instruct the insurer to notify the provider immediately of any dispute as to payment so the medical provider can exercise its legal rights.

This assignment of insurance rights and benefits includes an assignment of the right to pursue legal action against the insurance company for the recovery of any unpaid benefits.

Additionally, please be advised East Florida Premium Medical Care. LLC, through the assignment of the undersigned patient is hereby requesting to be notified of exhaustion of the policy benefits within 15 days of exhaustion, pursuant to Florida Statute 627.736 (6)(f) where it states that a dispute between the insured and the insurer, or between an assignee of the insured’s rights and the insurer, upon request, the insurer must notify the insured or the assignee that the policy limits under this section have been reached within 15 days after the limits have been reached.

I hereby authorize East Florida Premium Medical Care. LLC C to sign on my behalf, any and all documents including but not limited to HICFA forms in furtherance of obtaining payment for services rendered by East Florida Premium Medical Care. LLC I hereby authorize the release of all medical records associated with my treatment and/ or medical services provided to me in order for provider East Florida Premium Medical Care. LLC to exercise its legal rights in pursuit of any and all benefits from any and all insurance companies

I hereby assign to East Florida Premium Medical Care. LLC any benefits under the policy of insurance at issue for services and/or charges provided by East Florida Premium Medical Care. LLC regardless of whether an insurance company is listed or the incorrect insurance company is listed herein. I am assigning my benefits from any policy that would owe me insurance benefits for treatment rendered herein.

I have read, understood, and agreed to all of the above.

Notice Of Privacy Ractices

We may use and disclose your PHI (private health information) in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute.

We may use or disclose your PHI for worker’s compensation and similar programs.

We may use a sign-in sheet at the front desk and we may call you in to see the doctor by name.

We may contact you by mail or phone, at your residence, to remind you of appointments or to provide information about treatment alternatives. Unless you instruct us otherwise, we may mail you a postcard reminding you to make an appointment and we may leave a message for you on any answering device or with any person who answers the phone at your residence

You can make a reasonable request for us to use alternative methods of communicating with you in a confidential manner. These requests must be submitted in writing in a clear and concise fashion. We are not required to agree to your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when information is necessary to treat you.

Rights that you have:

You have the right to request restrictions on some of the uses or disclosures described above. Except as stated, we are not required to agree to such restrictions.

You have the right to inspect and obtain copies of your medical Information. (A fee for the costs of copying, mailing, labor and supplies associated with your request will be charged.)

You have the right to request amendments to your medical information. Such requests must be in writing, and must state the reason for the requested amendment. We will notify you as to whether we agree or disagree with the requested amendment. If we disagree with any requested amendment, we will further notify you of your rights.

You have the right to request an accounting of any disclosure we make of your medical information except for disclosures we make to you, to carry out treatment, payment or healthcare operations, as requested by your written authorization, as permitted or required under 45 CFR 164.502, for emergency or notification purposes, for national security or Intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law.

You have the right to receive a paper copy of this notice. To obtain a paper copy of this notice, please contact our office manager.

You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing and addressed to 7421 N University Dr, Suite 314, Tamarac, FL 33321. You will not be penalized for filing a complaint.

This privacy policy is subject to change as circumstances dictate. Any changes will be effective upon the release of a revised privacy policy, which will be made available to patients upon request.

Please sign and date below, acknowledging that you have read this policy and that you consent to the terms of our privacy policy as stated in this notice.

Letter Of Protection Authorization And Medical Assignment

East Florida Premium Medical Care. LLC from the share of my proceeds of any recovery as a result of the settlement or litigation of the accident on (Date of Accident) __________________, the unpaid balance for the reasonable and customary charges as determined by the insurance company, for professional services rendered by said hospital, physician, or other medical care provider, on my behalf. In the event of a dispute between my insurance carrier and my physician, hospital or medical care provider, any assignment of benefits executed by me to my said physician, hospital, or medical care provider shall serve as my authority for my said physician, hospital, or medical care provider to proceed against my insurance carrier in the method and manner as provided in Florida Statute. Said professional services to include those for the medically necessary and reasonable diagnosis treatment and care heretofore and hereafter rendered to me as well as those medical reports, consultations, with my attorney, and court appearances on my behalf. Payment of these balances as herein stated shall be the same as if paid by me.

I understand that this assignment in no way relieves me of my personal responsibility and obligation to pay my physician, hospital, or medical care provider for such charges as herein stated for such services rendered, and that such physician's, hospital's, or other medical care provider's fee for such services rendered is not contingent upon the outcome of this litigation.

I further authorize the before said physician, hospital, or medical care provider to furnish my attorney with a full report of the physician's, hospital's or medical care provider's treatment evaluation of me in regard to the said incident.

In exchange for this letter of protection, it is our understanding that all such related bills will be directed to this office and not to the client/patient and that client/patient's account will not be turned over to any type of collection agency or credit bureau, nor will any adverse credit information be reported against this client's credit during the pendency of this case and if this account is turned over to a collection agency or credit bureau, or if any adverse information is reported against this client's credit by you, directly or indirectly, this Letter of Protection is null and void and this law has no further obligation to you whatsoever.