DOCTOR'S LIEN

TO: _

RE: -----------=~--~~~------------(Patient's Name)

I hereby authorize Dr. L. Lee Smith to furnish my attorney and/or insurance company with a fullreport of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accidentin which I was involved.

I hereby authorize and direct my attorney and/or insurance company to pay directly to Dr. L. LeeSmith such sums as may be due and owing him for his professional services rendered me both byreason of this accident and by reason of any other bills that are due his office and to withholdsuch sums from any settlement, judgment or verdict as may be necessary adequately to protectsaid doctor. I hereby further give a lien on my case to said doctor against any and all proceeds ofany settlement, judgment or verdict which may be paid to my attorney and/or myself as the resultofthe injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to Dr. L. Lee Smith for all professionalbills submitted by him for service rendered me and that this agreement is solely for said doctor'sadditional protection and in consideration of his awaiting payment. And I further understand thatsuch payment is not contingent on any settlement, judgment, or verdict by which I mayeventually recover said fee.

(Patient Signature) (Date)

The undersigned being attorney of record for the above patient does hereby agree to observe allthe terms of the above and agrees to withhold such sums from any settlement, judgment, orverdict as may be necessary to adequately protect the said doctor named above.

(Attorney Signature) (Date)

Attorney: Please date, sign, and return one copy to Dr. L. Lee SmithKeep one copy for your records.

OFFICE OF INSURANCE REGULATIONBureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement FormPersonal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1. The services set forth below were actually rendered. This means that those services have' already beenprovided.

2. Ihave 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.This means that no person has initiated contact with me and/or persuaded me to use the doctor or licensedprofessional, clinic, or medical institution that provided the services.

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 amountspaid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, upto $500.

The undersigned licensed medical professional affirms the statement numbered 1 above and also:

A. Ihave not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicitedto make a claim for Personal Injury Protection benefits.

B. r have explained the services rendered to the insured person, or his or her guardian, sufficiently for that personto sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevantinformation has been provided therein. This means that each request for information has been responded totruthfully, 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 beenupcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined bySection 627.732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Insured Person (patient receiving treatment) or Guardian of Insured Person:

Signature DateName (PRlJVT or TYPE)

Licensed Medical Professional Rendering Treatment (Signature by his or her own hand):

--L. Lee SmithSignature DateName (PRlNTor TYPE)

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement.ofClaim or an .•application containing any false.jncomplete,: or misleading information is guilty of a felony of the third degree' per':SectionSt7.234(l)(b), Florida Statutes. '. ..... .. ........., ..

Note: The origtnal ofthis form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutesand may not be electronically furnished. Failure to furnish this form may result in non-payment O,fthe claim.' ' .

OIR-Bl-157110/03

_._._-_._ .._.---_._----

Patient Consent foro Use and Oisc!osureof ProteC"'..ed Haaftnfnfarmation

An Boca Chiropracnc

Aii Boca Chlropractic's NOTIce of Privacy Practices provides e more complete description of such usesand clsclosures ..

have the right to revrS;N me Notice of P~acy Practices prior to signing this consent fl.J! BocaChiropractic reserves the right to revise ITSNOTIceof Privacy Practices at anytime. A revtsec Notice ofPrivacy Practices may be obtained by fonrifaming a "witten rscuest to Aff Boca Chirooracfiors Tam; SmIThat An Boca Chiropractic. .. •

l.-'Vith this consent" .~l Boca Chiropractic may call my home or other alternative location and reave ismessage on voice mail or in person in reference to any items mat assist the practice in canying out TPO,such as appointment remtnders, insurance items and any cans pertaining to my clinical care, includinglaboratory results among otnsrs. .

'vVith this consent, .Al! Boca Chiropractic may mali to my home or other attamative ioc<=.-tionany items thatassist the oractice in carrying out TPO~such as:appclrrtment remrnder cards anc patient s=~ements asfong as t~eyaremarked Personal and ConfidennaL

Vif1th thls consent, .tV! 80ca Cniropractic may e-{Dsii to my heme or other alternative location any itemsmat assist the practice in canylng OU! TPO, such as eppointment reminder cards and patient stai:&ments.i have +h.o nqr+ to recuest :that jlJl Boca Chiropractic restrict how it uses or discloses my PHi to carry outTPO_~H~~~~~;,the p:actIce is not required to agree to mf requested rsstnctions, but if itdoes, it is boundby fuIs agreement

~ . .. ~..,.. " am" cnn.'""J;._· ntin.•.0_ to All B~~ ~Chiinnracnc's use and disclosure of my- PH: to c;;arrf ot.:-itiy SigOH1:9 .u lIS T01m", - - ~ - r

!PO.

. ~~ O,~='.,..,..,vconsent in lJmtina except to the ex-..entthat the pracnee has already made disclos:rres inrpav ·=v "'- l"~ ~.. 11 B . ro·· . mav~~!ian~euponmy prior consent ff! de not slgn this consent, Of later revoke it, AI cce ,-,nrropractlc ~

decline to ·prOvide tr&iment to me .

. G ..<:::1·cnaturs of Patient or Legal uarcran~.::::t aLl'_ ;..0.

Patient's Name

IRREVOCABLE ASSIGNMENT OF BENEFITSIPOLICY RIGHTSPATIENT:I, the undersigned patient hereby assign the rights and benefits of insurance of theapplicable personal injury protections, medical payments, and/or other insurance to L.Lee Smith, the provider of services and/or supplies rendered for treatment of the personalinjuries that were sustained in the accident on (Date) and coveredby Personallnjury Protection (PJ.P) Coverage of other insurance coverage in accordancewith Florida Statute 627.736 (5). I,the undersigned patient agrees to pay any applicabledeductible or co-payment not covered by the P.I.P or other insurance coverage. I have.read the information herein and is true and to the best of my knowledge.This assignment includes, but is not limited to all rights to collect benefits directlyfrom the insurance company for services that I have received; and all rights toproceed against the insurance company obligated to provide benefits in any actionincluding legal suit, if for any reason the insurance company fails to make paymentsof benefits of which I am due ..Specifically, this assignment includes the right to collectpayment for the reasonable costs connected with copying and mailing records to theinsurer at the insurer's request and in accordance with Florida Statute 627.736 (6). Thisassignment also includes any right to recover attorney's fees and costs for such actionbrought by the provider as Patient's assignee. I agree that L. Lee Smith may select anyattorney helshelit wishes and understand and agree that the attorney selected by themmay be different than the attorney handling my personal injury/bodily injury claim orcase.As part of this assignment of rights and benefits, I hereby instruct the insurance carrierthat in the event the subject medical benefits are disputed for any reason, includingmedical reasonableness and or necessity that the amount of benefits claimed by L. LeeSmith is to be set aside and not disbursed until the dispute is resolved. As part of thisassignment of rights and benefits, I further instruct the insurance carrier to notify theprovider immediately of any dispute as to payment so that he/she/it may exercise theirlegal rights. I understand that any person who knowingly files anything containing anyfalse, incomplete or misleading information with the intent to injure, defraud, or deceiveany insurance company is guilty of a felony of the third degree. I have read theinformation herein and it is true and correct to the best of my knowledge and belief.

PATIENT SIGNATURE DATE

PATIENT'S PRINTED NAMEPROVIDER: L. Lee Smith, D.C., P.A.The undersigned on behalf ofL. Lee Smith, D.C., P.A. hereby accepts assignment of theinsurance rights and benefits for the service rendered to ---------------------(The Insured) and to be paid directly to L. Lee Smith, D.C., P.A. under

(The Insurer) Personal Injury Protection (P.I.P) orother insurance coverage with in accordance with Florida Statute 627.736 (5).

W1TNESS SIGNATURE PROVIDER REPRESENTATIVE'S SIGNATUREIDPAA General Compliance Made Easy 954-202-0106

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such carer it is essential forboth to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and themethod that will be able to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction ofvertebral subluxation. Our chiropractic method of correction is-by specific adjustments of the spine.

-Health: A state of optimal physical, mental and social well-being, not merely the absence of disease orinfirmity.

vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column whichcauses alterationof nerve function and interference to the transmission of menta! impulses! resulting in alessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However,if during the course of a chiropractic spina! eveluation, we encounter non-chiropractic or unusual findingsr

we will advise you. If you desire advice, diagnosis or treatment for those findlnqs, we will recommendthat you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regardingtreatment prescribed by others. OUR ONLY PRACITCEOBJECITVE is to eliminate a major interference tothe expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebralsubluxations.

I, have read and fully understand the above statements.All questions regarding the doctors objectives pertaining to my care in this office have been answered tomy complete satisfaction. I therefore accept chiropractic care on this basis.

Signature, Date, _

AUTHORIZATIONF9R INSURANCE

I certify that I have read and understand the enclosed information to the best of my knowledge. The enclosed questions have beenaccurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize thechiropractor to release any information induding the diagnosis and the records of any treatment or examination rendered to me ormy childduring the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request myinsurance company to pay directly to the chiropractor or chiropractic group insurance benefits otherwise payable to me. Iunderstand that my chiropractic insurance earner may pay less than the actual bill for services. I agree to be responsible forpayment of all services rendered on my behalf or my dependents.

X. Dare. _

CONSENT FOR X-RAY

I hereby authorize Dr. L. Lee Smith and whomever he designates as his assistant to take X-rays of myself(or said minor).

Signature Date, _

Payment Authorization

I hereby authorize and direct you, my insurance company, and/or, my attorney, to paydirectly to Dr. L. Lee Smith such sums as maybe due and owing this office for servicesrendered me, both by reason of accident or illness, and by any disability benefits, medicalpayments benefits and to withhold such funds from any disability benefits, medicalpayments benefits, no-fault benefits, health and accident benefits, workmen'scompensation benefits, or any other insurance benefits obligated to reimburse me or fromany settlement, judgment or verdict on my behalf as my be necessary to adequatelyprotect said office I hereby further give a lien to said office against any and all insurancebenefits named herein, and any and all proceeds of any settlement, judgment or verdictwhich may be paid to me as a result of the injuries or illness for which I have been treatedby said office. This is to act as an assignment of benefits and an assignment of directpayment to the extent of the office's services provided.

In the event my insurance company is obligated to make payments to me upon thecharges made by this office for services rendered, refuses to make such payments, upondemand by me or this office, I hereby assign and transfer to this office any and all causesof action that I might have or that might exist in my favor against such company andauthorize this office to prosecute said cause of action either in my name or in the office'sname and further I authorize this office to compromise, settle or otherwise resolve saidclaim or cause of action as they see it.

I authorize this office to release any information pertinent to my case to any insurancecompany, adjuster or attorney to facilitate collection under this assignment, lien andauthorization. I agree that the above mentioned office be given power of attorney toendorse/sign my name in any and all checks for payment of my doctor bill. I understandthat health and accident insurance policies are an arrangement between and insurancecarrier and myself.

I understand that I remain personally responsible for the total amounts due this office fortheir services and will be billed for any account balance. I further understand and agreethat this assignment, lien and authorization do not constitute any consideration for thisoffice to await payments and they may demand payment from me immediately uponrendering services at their option.

I further understand and agree that if this office must take any action to collect andoutstanding balance on my account, I will be responsible for payment of and willreimburse this office for all costs of such collection efforts, including but not limited toall court costs, interest incurred, collection fees and all attorney fees.

For office use only:Co-pay is $ --"per visit while under active care toward services rendered.

Patient Signature, ~Date _

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