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Chiropractic Personal Injury Welcome Packet Form

Auto Accident Mechanism of Injury Form Addendum(with Intake-Doctor KEY)

Type of Vehicle you (driver) were in:
Type of Vehicle other driver was in:
Did you head hit the headrest?
Did your body contact part(s) of the interior of the vehicle?
Were you surprised by the impact?
If no, how did you brace?
The next form is the Assignment, UCC Lien, and Authorization. 
This allows us to serve you to make sure all benefits are verified. It allows us to communicate and receive correspondence from the insurances and attorneys. Again we do not assume responsibility for collections, but this form helps us to collect.

ASSIGNMENT, UCC LIEN, AND AUTHORIZATION

FOR DIRECT PAYMENTS BY MY PAYERS TO NEWTON CHIROPRACTIC & WELLNESS CENTRE

PURPOSE AND CONSIDERATION; TERMS WHICH PAYERS MAY BE REQUIRING. The purpose of this Assignment & UCC Lien is to assist the Office and any duly-authorized A/R management agent of the Office in obtaining Proceeds from various Payers (including without limit my Attorney) for the payment of my Charges. In consideration for receiving / continuing health care at the Office based on terms which Payers may be requiring, as well as on terms set forth in various documents of the Office, I agree to the following and direct all Payers as follows:




DEFINITIONS. In this Assignment & UCC Lien, the following terms shall have the following meaning: "Office" and "Clinic" shall refer to Newton Chiropractic & Wellness Centre located at 383 Elliot Street, Suite 250, Newton Upper Falls, Massachusetts, 02464; "Assignment & UCC Lien Document," "Assignment & UCC Lien," "Assignment & Lien," and other like phrases shall refer to this document. "Payer" shall refer to without limit any insurance carrier, health benefit plan administrator and fiduciary, health maintenance organization, preferred and independent provider organization, attorney, adjuster, claims handler, medical examiner, individual reviewer or review entity, at-fault party, individual, and any other entity, which may elect or be obligated to pay or disburse Proceeds, either now or in the future, or which may be involved directly or indirectly in determining the obligation to pay or disburse Proceeds, either now or in the future; "Proceeds" shall include without limit, the proceeds from any settlement, judgment, or verdict, the proceeds from any promise to pay or reimburse, the proceeds relating to "health-care insurance receivables" and "payment intangibles" as such are defined by the applicable Uniform Commercial Code, and the proceeds relating to the following benefits, plans, or coverages: individual and group health benefits, Medicare and Medicaid, workers' compensation, disability, liability, uninsured and underinsured motorist, no-fault, medical expense or payments benefits ("Medpay"), personal injury protection ("PIP"), lost wages, lost services, property damage, errors & omissions, and malpractice; "Charges" shall include without limit the full fees for the Office's goods and services (including without limit treatment, diagnostic services, medical equipment, supplies, supplements, narrative reports, photocopies, pre-authorization requests, no-shows, depositions, and testimony), whether rendered before or after the date of this Assignment & UCC Lien, any Additional Costs incurred by the Office as defined herein, delinquency penalties and interest to the maximum extent permitted under law or at the annual rate of eighteen percent (18%), whichever is greater, and any other charges incurred by me at the Office; "Additional Costs" shall include without limit any costs incurred by the Office relating directly or indirectly to (i) the goods or services associated with my Charges, (ii) this Assignment & UCC Lien, (iii) the application or enforcement of any law relating to the issue of the Office's Charges, secured interests or its goods and services, (iv) any effort or action to collect my Charges either from me or from any Payer, or (v) any legal or medico-legal action, process, or claim of any nature against, or by, the Office or its employees for any reason relating to the foregoing items, (i)-(iv), of the previous clause ("Medico-Legal Process"). "Medico-Legal Process" shall include without limit civil and administrative proceedings, mediation, arbitration, interpleader actions, cross-claims or counterclaims, requests for reconsideration, independent reviews, and internal appeals. Costs associated with such Medico-Legal Processes shall also include without limit any pre- and post-judgment costs, filing fees, service of process charges, and attorney's fees. In determining the Office's Charges, I hereby waive any defense or argument that such costs shall not apply or be awarded based on the claim that the Office's goods or services were somehow (i) not sufficiently necessary or effective, related to an accident, documented or otherwise warranted, or (ii) inappropriately directed, delivered, conducted or administered.

ASSIGNMENT AND UCC LIEN TERMS; AUTOMATIC RE-EXECUTION AND RE-AFFIRMATION. (i) Assignment Terms: I hereby assign to the Office to the extent permitted by law, but only to the extent of my Charges, all of my claims to, rights to, and interests in, Proceeds, whether resolved or unresolved, including without limit ownership rights, which I may have now or in the future relating directly or indirectly to my Charges, condition, or causes of my condition ("Claims to Proceeds"), including without limit any and all causes of action, receivables, payment intangibles, and remedies that I might have against or with respect to any Payer now or in the future, and the right to prosecute, seek, settle, or otherwise resolve such Claims to Proceeds either in my name or in the Office's name and as the Office otherwise sees fit. I agree that this assignment shall be effective as of the date and time the initial cause of my condition occurred. (ii) UCC Lien Terms: I further intend for this Assignment & UCC Lien to create a security interest under the applicable Uniform Commercial Code; accordingly, I hereby grant to the Office a primary, non-contingent security interest in all of my Claims to Proceeds to the extent permitted by law for the purpose of securing payment of my Charges ("UCC Lien"), the attachment and perfection of which shall relate back to, and be effective as of, the date and time that the initial cause of my condition occurred; I further authorize the Office to file the form(s) normally filed with the secretary of state or other governmental agency relating to such security interests, and to make such filings in all relevant jurisdictions as the Office sees fit in its sole discretion; I agree that once payment in-full has been made towards all outstanding Charges to the full extent permitted by law or contract and also as defined by my agreement with the Office, such security interest shall be removed or terminated solely upon my written request sent through the U.S. Postal Service Certified Mail. (iii) Other Assignment and UCC Lien Terms: Consistent with the foregoing terms, I hereby direct any and all Payers, to pay the Proceeds directly to, immediately to, and exclusively in the name of, the Office to the full extent of my Charges. To the extent that any law, including without limit a lien statute, purports to limit, reduce, or modify the distribution of Proceeds in any manner inconsistent with this Assignment & UCC Lien including without limit through the reservation of a portion of the Proceeds exclusively to me, I hereby waive such limits, reductions, or modifications. Such waiver shall not adversely affect or prejudice any rights which the Office may have and elect to exercise under said law. I agree that following the original execution of this Agreement, the Office shall be entitled at any time hereafter to request that I re-execute and re-affirm an identical version of this Agreement, such as in cases where additional causes of action may have arisen. In the event that the Office presents an identical version of this Agreement, along with a request for payment of the Office's Charges or for any additional information required to be disclosed under this Agreement, and I fail to promptly provide such payment or information within five (5) days of such request, this Agreement shall be deemed to be automatically re-executed and re-affirmed by me effective as of the date of the request. I hereby waive any defense, reasonable or unreasonable, and regardless of any action by the Office which I claim to be inconsistent with the terms herein that such actions on my part shall not constitute a re-execution and re-affirmation of this Agreement.

SPECIFIC DIRECTION TO ANY ATTORNEY I RETAIN, SUCH AS IN ACCIDENT CASES. In the event that I retain one or more attorneys relating to my Claims to Proceeds, I hereby direct (and the Office hereby requests) each attorney to review the terms of this Assignment & UCC Lien, including without limit the fact that I may become responsible for various costs arising hereunder. Accordingly, I respectfully request that each attorney not unilaterally assume to arbitrate potential disputes relating to this Assignment & UCC Lien. I hereby direct (and the Office hereby requests) each attorney to provide immediate notice to the Office and to any duly authorized A/R management agent of the Office regarding any Proceeds received by the attorney, to promptly pay the Office in-full out of such Proceeds, and to provide a full accounting of such Proceeds to the Office and to any duly-authorized A/R management agent of the Office. I agree that the purpose of such Proceeds shall be primarily to pay my Charges. If I have a dispute with the Office, attorney, or any other party for any reason, any remedies I may have shall not include instructing my attorney to withhold or delay payment of Proceeds to the Office for any portion of the Charges. I further agree to and hereby irrevocably waive any present or future right I may have, whether arising under a "Common Fund Doctrine" or other legal basis, to require the Office to absorb the costs associated with, or otherwise assume responsibility for, any portion of my attorney's fees and costs, or other expenses of obtaining Proceeds.



DISCLOSURE DIRECTIVES TO ALL PAYERS. I hereby direct each and every Payer to immediately release to the Office and to any duly-authorized A/R management agent of the Office any Pertinent Information relating to (a) any coverage I may have and (b) any Proceeds Determination by the Payer relating to the Office's Charges. "Pertinent Information" shall include without limit the amount of total coverage available and remaining, the amount of any outstanding claims which the Payer has received from any claimant relating to my condition, and the terms of any resolution or settlement of my Charges by the Payer. "Pertinent Information" shall also include without limit copies of all documents, records, settlement agreements, and other information (a) relied upon by the Payer in making a Proceeds Determination, or (b) was submitted, considered, or generated in the course of making a Proceeds Determination without regard to whether such document, record, or other information was relied upon in making the Proceeds Determination. "Proceeds Determination" shall include without limit any determination by the Payer to pay, settle, reduce, deny, or delay payment of any Proceeds relating to the Office's Charges, as well as a decision to refer the Charges to an independent review or audit, utilization review, or independent medical exam. I further authorize and direct the Office to release any information relating any services rendered to or for me by the Office to all Payers, including without limit a copy of my Charges and a copy of this Assignment & UCC Lien, unless otherwise agreed to in writing.

DISCLAIMERS. I UNDERSTAND THAT THE OFFICE MAY RETAIN THE SERVICES OF AN A/R MANAGEMENT AGENT TO ASSIST THE OFFICE IN MANAGING ITS PERSONAL INJURY ACCOUNT RELATING TO MY CHARGES. I UNDERSTAND THAT THE OFFICE AND/OR A/R MANAGEMENT AGENT MAY HAVE NEED FROM TIME TO TIME TO CONTACT ME REGARDING MY CHARGES AND THE MANAGEMENT OF MY ACCOUNT WITH THE OFFICE. I UNDERSTAND AND AGREE THAT NOTHING IN THIS ASSIGNMENT & UCC LIEN, OR ANY INTERACTION I MAY HAVE EITHER WITH THE OFFICE AND/OR A/R MANAGEMENT AGENT, OR ANY INTERACTION BETWEEN SUCH ENTITIES AND ANY PAYER, SHALL CONSTITUTE LEGAL ADVICE OR ESTABLISH AN ATTORNEY-CLIENT RELATIONSHIP. I UNDERSTAND THAT ALL SUCH INTERACTIONS, TO THE EXTENT THEY OCCUR, SHALL BE FOR THE PURPOSES OF HELPING THE OFFICE AND/OR A/R MANAGEMENT AGENT TO MANAGE THE OFFICE'S PERSONAL INJURY ACCOUNT EXCLUSIVELY FOR THE BENEFIT OF THE OFFICE, AND SHALL NOT BE CONSTRUED AS BEING PROVIDED FOR THE BENEFIT OF HELPING ME TO SETTLE ANY CAUSES OF ACTION I MAY HAVE AGAINST ANY ENTITY OR INDIVIDUAL. I UNDERSTAND AND AGREE THAT IF I HAVE QUESTIONS OF A LEGAL NATURE, I WILL SPEAK WITH AN ATTORNEY AT LAW.



MISCELLANEOUS. Except as provided in this paragraph, this Assignment & UCC Lien shall not be modified or revoked without the expressed, written consent of the Office. I hereby revoke, with the Office's consent, the terms of any previously signed documents, but only to the extent those terms conflict with the terms of this Assignment & UCC Lien. I agree that each and every provision of this Assignment & UCC Lien is reasonably necessary. However, should any provision of this Assignment & UCC Lien be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Assignment & UCC Lien shall, nevertheless, remain in full force and effect. I agree to indemnify and hold the Office harmless for Charges, including without limit any Additional Costs as defined herein. In the event that I file for bankruptcy, I waive any objection to the Office proceeding after any Payer for receiving reimbursement of the Office's Charges. This Assignment & UCC Lien shall be governed under the laws of the state where the Office is located, and is performable in the county where the Office is located. In any action based upon this Assignment & UCC Lien, I hereby consent to personal jurisdiction and venue of any court in said county and waive all objections based on improper jurisdiction, venue, or forum inconvenience. I further waive any statute of limitations which may apply in an action based upon this Assignment & UCC Lien.



I have read, understood, and agree to the terms of this Assignment & UCC Lien.

This is a service designed to help you, in no way are we taking full responsibility for any failure of your insurance companies to pay in full. Please be aware that the insurance companies may not make you aware of all the benefits you have available. This process has been designed to make you more aware of the benefits you may have.

PERSONAL INJURY AUTOMOBILE ACCIDENT QUESTIONNAIRE

Do you have a copy of the police report?(If yes, please provide our office with a copy of this report)
Was a ticket or citation issued by a police officer as a result of the accident?
Who was at fault, or who received the ticket or citation?*
Please select one option
Did the accident involve the hit and run?
Are you yourself licensed to drive? (If yes, please provide our office a copy of your license)
Was the car in which you were in at the time of the accident registered?
Were you in your own vehicle or someone else's at the time of the accident?*
Please select one option

If you were in someone else's vehicle, please answer the following:

Your Auto Insurance Company (at the time of the accident, if different from above)

Do you reside with a blood relative, legal relative or spouse who owns their own vehicle or is insured under some other auto policy?(check all that apply)*
Please select at least one option
Do you have any information, including insurance information, concerning the other parties involved in the accident?(If yes, please provide our office with a copy of this information)*
Please select at least one option
Have you been in contact with the other party's insurance company regarding this claim?
Have you been in contact with the other party's insurance company regarding this claim?
Was there any property damage to any of the vehicles as a result of the accident?
Check all that apply
Are you currently represented by an attorney?
If no, do you wish to retain an attorney?

Other Accident Details 

Have you ever been in a previous auto accident? Describe all instances, giving approximate dates of the accidents, as well as the injuries sustained and names of attorney who represented you. 

Were you a Medicare Patient at the time?
Were you a Medicare Patient at the time?
Were you a Medicare Patient at the time?
The next page is the Personal Injury Protection Application (PIP Application) form.


The highlighted areas must be filled out prior to care. Most insurances require this form, in order to fully open your claim to benefits. When you complete this form, it allows us to look into accepting assignment on your case.

APPLICATION FOR BENEFITS – PERSONAL INJURY PROTECTION


To enable us to determine if you are entitled to benefits under Massachusetts personal injury protection law, please complete
this form and return it promptly: Newton Chiropractic and Wellness Centre
383 Elliot St, Suite 250, Newton, MA 02464
Tel.617-964-3332 Fax.617-332-7601

At the time of the accident:

Were you the driver of the motor vehicle?*
Please select one option
Were you a passenger in the motor vehicle?
Were you a pedestrian?*
Please select one option
Were you a member of vehicle owner's household?
As a result of this accident were you injured?

IF YOU ANSWERED YES, COMPLETE THE REST OF THIS FORM. 

IF YOU ANSWERED NO, SIGN HERE AND GO TO THE NEXT SECTION OF THIS FORM. 

If you were treated in a hospital were you an:
Have you received, OR are you eligible for any payment under a policy of health, sickness. disability, or contract of agreement with a group, organization partnership, or corporation to provide pay for/or reimburse the cost of medical expenses?
List names & addresses of employer and other employers current and for one year prior to accident date:
As a result of your injury, have you had any other expenses?

IMPORTANT: 

1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION.

2. YOU MUST ALSO SIGN ANY ATTACHED AUTHORIZATION(S).

3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE.

The next page is the Health Insurance Election form.


If you choose option 1, it may force auto insurances to pay, even if you have health insurance. What this means is you may have less deductibles. Do be aware that if they don't pay, we may bill your health insurance.

HEALTH INSURANCE ELECTION

(Accident Cases)

How would you like for us to handle your health insurance? Please choose one:

Option 1 – Either - I Do Not Have Health Insurance - OR - I Don't Want You to File My Health Insurance

I want the services we discuss, but either I don't have health insurance or I don't want you to bill or submit paperwork to my health insurance. You may keep any health insurance which I may have and that I provide to you on file, but only for the purposes set forth in, and as consistent with, your Financial Policy. You may ask to be paid now or later as I am responsible for payment. I understand that if my claims or forms are not submitted to my health insurance in a timely manner, my payer may decline to pay on my claims and I may not be able to appeal this decision.


Option 2 -- I Want You to File My Health Insurance and Also to Help Me Verify My Benefits. To Help You Get Paid, I'll Make Partial Payments and/or Sign an Assignment & Financial Policy

I want the services we discuss, but I also want you to bill my health insurance for an official decision on payment even if this is an accident case. Please help me verify any Terms of Non-Coverage. If I have any questions, I will verify my coverage on my own. You may ask to be paid now or later for estimated co-pays, co-insurance, deductibles and other Non-Covered amounts. I understand that these are just estimates. If my condition is due to an accident case, I would ask that you delay from collecting such amounts as described in your Financial Policy. With this in mind, I agree to the terms of the Financial Policy. In the event that my health insurance delays or Denies Payment, I will be responsible for payment as described in the Financial Policy, but I understand that I will be able to appeal to my health insurance following its directions.


Option 3 -- I Want You to File My Health Insurance, But I'll Pay in-Full at the Time of Service or Pre-Pay. If Insurance Pays, You'll Give Me a Refund

I want the services we discuss, but I also want you to bill my health insurance for an official decision on payment. However, you may ask to be paid now. If my health insurance does pay, you will refund any payments I made to you, less co-pays, co-insurance, and deductibles, and also discounts (Mandatory Fee Reductions) as described in your Financial Policy. In the event that my health insurance Denies Payment, I can appeal to my health insurance following its directions.


Important: I understand that in certain circumstances, the Office may have a policy of not filing health insurance or law may actually control or
regulate the filing of insurance. This election will remain in effect until a new election is signed with the Office's consent. This election supersedes
any prior health insurance election.

Select an option:

TO: ALL PATIENTS BEING TREATED FOR INJURIES DUE TO:

  1. An automobile accident
  2. A personal injury accident (slip and fall)
  3. A work-related accident

YOU MUST NOTIFY YOUR CHIROPRACTOR OF ANY UPCOMING "INDEPENDENT" MEDICAL EXAMINATION.

Most insurance companies require an "independent" exam of the insured, by a doctor who works for them through an agent. IT IS EXTREMELY IMPORTANT THAT YOU KEEP ANY APPOINTMENTS SCHEDULED BY THEM. FAILURE TO DO SO CAN RESULT IN LOSS OF MEDICAL PAYMENTS, MAKING YOU (AND NOT THE INSURANCE COMPANY) RESPONSIBLE FOR YOUR BILLS! PLEASE NOTIFY YOUR CHIROPRACTOR IMMEDIATELY IF YOU ARE SCHEDULED FOR ANY INSURANCE EXAMS.


APPOINTMENTS
KEEPING YOUR APPOINTMENTS for TREATMENTS at our office is EXTREMELY IMPORTANT for several reasons:

  1. The doctor has recommended these appointments specifically for your condition and failure to respond may jeopardize your
    rate of improvement.
  2. A third-party payor (insurance company) may not be responsible to pay for medical services to patients who do not follow
    doctors' recommendations.
  3. Appointments reserved for you that are not kept become cost-ineffective for us as these appointments could be used for
    others who need our services.


**IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT AS SCHEDULED, FOR ANY REASON, PLEASE NOTIFY THIS OFFICE IN ADVANCE, AND RESCHEDULE YOUR NEXT APPOINTMENT FOR THE NEXT AVAILABLE TREATMENT DAY:


Chiropractic appointments - a 24 hour notice is required to cancel or you will be charged a $25 fee.

Massage/Acupuncture appointments - a 48 hour notice is required to cancel or you will be charged an $85 fee.


**LATE CANCELLATION/NO SHOW CHARGES ARE BILLED TO THE PATIENT, NOT THE INSURANCE.

Please note - if you are unable to make your appointment but you are able to give your space to a friend or family member who does pay for that time, you will not be charged. Also, we will do our best to try and fill your appointment but that is often difficult on short notice. Of course, emergencies will be taken into consideration.


If we do not hear from you after missing an appointment, our staff will call to reschedule your next appointment. If at ANY TIME you experience transportation problems, etc. please notify the doctor IMMEDIATELY. I have read and understand the above information as attested:

The next page is the Financial Policy Agreement
When you sign the following, it allows us to look into accepting assignment on your case. We will sit down with you and serve you because we have experience and can guide you, but you need to help us. You can pay cash or provide us with all information requested in this packet.

FINANCIAL POLICY AND AGREEMENT


I, the undersigned, in consideration of the Office's services, agree to the following terms:


Definitions. In this Agreement, "Office" and "Clinic" shall refer to Newton Chiropractic & Wellness Centre, located at 383 Elliot Street, Door F, Suite 250,
Upper Newton Falls, MA, 02464. "Financial Policy" or "Agreement" shall refer to this document.


Authorization to Sign My Name on Payments; Transfer of Credit Balances. I authorize the Office to endorse or sign my name on any and all
payments listing me as a payee which are received by the Office for payment of Charges incurred by me, my spouse or my dependents. In such cases,
my printed name, followed by the phrase, "(by [Name of Office])," shall serve as a properly authorized endorsement. I further authorize the Office to apply
any credit balances on my Charges to any other outstanding Charges still owed by me, my spouse, or my dependents, regardless of whether these other
Charges are related to my condition.


Personal Responsibility for My Charges. I understand that I remain personally responsible for my Charges and that at any time, I can request a copy of
my total Charges from the Office. Except where provided otherwise by law or by contract, I agree to pay the full amount of my Charges to the Office
promptly upon its demand. I understand that the Office's Assignment does not constitute an agreement by the Office to await payment of my Charges. I
agree that any delay by the Office in making demand for payment, any delay in paying the full amount of my Charges, and any partial payments received
by the Office towards my Charges, shall not constitute acceptance of any installment payment plan, shall not constitute a waiver of the Office's right to
receive payment-in-full promptly upon demand, and shall not constitute an "accord and satisfaction" of my Charges, regardless of any such terms or
restrictions indicated on, or included with, any payments. I also agree that my account with your Office shall be construed as in "default" on the earlier of
the following dates: (a) a Payer fails to pay any or all of the Charges in-full and directly to the Office upon receipt of those Charges within thirty (30) days
or the period established by the earliest prompt pay deadline applicable to the Payer (whichever occurs later), (b) I do not pay any or all of the Charges infull within fourteen (14) days of request, or (c) the Office attempts to charge my credit card in compliance with a written Payment Arrangement, but the
charge is declined or not approved.


Personal Responsibility for Verifying the Limitations in My Coverage; Financial Responsibility for Non-Covered Charges. I understand that in any
given situation, a Payer may initially refuse to make payment to the Office, may delay payment for an indefinite or unreasonable amount of time, or may
actually request a refund from the Office after making payment, and do so either in whole or in part with respect to any given Charge incurred at the Office
(collectively, "Deny Payment"). For example (without limiting this Agreement), I understand that a Payer may Deny Payment, stating that the Charge is "not a
covered benefit" under its policy or exceeds some other limitation. I further understand that a Payer may Deny Payment stating that the individual provider who
actually renders the treatment or procedure is out-of-network. I also understand that a Payer may claim, based on internal criteria, that a particular Charge is
or was not medically necessary or was not sufficiently documented, and should therefore be denied or downcoded. I also understand that a Payer may require
certain Charges to be pre-certified or pre-authorized. In the event that my condition arose from an accident, I further agree to the terms of the Office's Auto /
Work Comp Advance Beneficiary Notices as applicable. I understand that there may be many other situations where a Payer may Deny Payment based on a
particular contractual term applicable to me or to the Office (collectively, "Terms of Non-Coverage"). To the extent permitted by law or by contract, I agree that I
am solely and exclusively responsible for verifying all Terms of Non-Coverage prior to incurring any Charges at the office. I agree that if I have any questions
about the Terms of Non-Coverage, I can request copies of the Office's verification (e.g., eligibility, pre-authorization) forms to gain further understanding. I
agree that should the Office assist me in any way in the verification, pre-authorization, or billing process, I assume the risk that the Payer and/or the Office may
in my opinion not accurately understand and/or communicate the Terms of Non-Coverage and/or bill my Charges to my Payers. Should any Payer Deny
Payment, or should any Payer be likely to Deny Payment as determined by the Office in its sole discretion, I agree that I am personally, fully, and immediately
responsible for the portion of my Charges denied or likely to be denied. In no event shall I hold the Office responsible or liable in any of the foregoing
instances.


Direction to the Office to Apply the Lowest Mandatory Fee Reduction When Two or More Payers Are Involved. Unless otherwise agreed to in
writing, I authorize the Office to submit my Charges, as well as a copy of the Assignment & Lien, to any and all Payers, not including in accident cases my
health benefit plan or Medicare. Notwithstanding the foregoing, in the event that the Office determines in its sole discretion that it has any reasonable
basis for either submitting or not submitting my Charges and/or other documentation to a Payer, I hereby authorize the Office to take such action without
condition or restriction. I understand that some or all of these Payers may utilize fee schedules which (a) the Office has agreed to accept, directly with said
Payers in writing, or (b) law expressly imposes on the Office to accept (collectively, "Mandatory Fee Reductions"). I further understand that the Mandatory
Fee Reductions imposed on the Office with respect to one Payer may exceed the Mandatory Fee Reductions imposed on the Office with respect to
another Payer. In such an event, I hereby authorize and direct the Office insofar as permitted by law to apply the lower of the two Mandatory Fee
Reductions to its Charges. I further agree that in the special event that Mandatory Fee Reductions are imposed on the Office by virtue of laws which
regulate or restrict "balance billing," I hereby waive the application of such laws to the extent permitted by law. In the event that no Mandatory Fee
Reductions are actually imposed on the Office with respect to a Payer, I authorize and direct the Office to collect up to its full Charges from such Payer.


Miscellaneous Provisions. Except as provided in this paragraph, this Agreement shall not be modified or revoked without the expressed, written consent
of the Office. I hereby revoke, with the Office's consent, the terms of any previously signed documents, but only to the extent those terms conflict with the
terms of this Agreement. I agree that each and every provision of this Agreement is reasonably necessary. However, should any provision of this
Agreement be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of
this Agreement shall, nevertheless, remain in full force and effect. This Agreement shall be governed under the laws of the state where the Office is
located, and is performable in the county where the Office is located. In any action based upon this Agreement, I hereby consent to personal jurisdiction
and venue of any court in said county and waive all objections based on improper jurisdiction, venue, or forum inconvenience. I further waive any statute of
limitations which may apply in any action based upon this Agreement. I have reviewed the Office's "Assignment & Lien", Health Insurance Election, and, if
applicable, Auto / Work Comp Advance Beneficiary Notices, and further agree to the terms and definitions set forth in these documents as applicable.
Said documents are incorporated herein by reference. In the event that my condition is related to an accident, including without limit automobile accident, I
understand that there will be an administrative fee necessary to cover the costs of verifying multiple Payers, filing and terminating liens, and submitting
notices of same to Payers.


I have read, understood, and agree to the terms of this Agreement.

The next form is the Advance Beneficiary Notice.
1. Most people choose Option 1.
    • Option 1 is if you want the option to choose any additional services or products that we may offer, even though some are not billable to insurance.
    • Please see the following page for examples of services that are not billable to the insurance.
    2. Option 2 is if you do NOT want any services or products which would be out of pocket expense at the time of service.
    3. Option 3 is if you decide you do not want any services/products on your PI claim. If you choose this option, this means you do not want us to bill the auto insurance, and you seek an alternate payment method.
    AUTO / WORK COMP
    ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE

    Your auto or workers compensation insurance does not pay for everything, even some care that you or your health care provider has good
    reason to think you need. We expect insurance(s) may not pay for the some of the supplemental services (D) below:

    (D)(E) Reason your insurance(s) may not pay:(F) Estimated Cost:
    Secondary supportive services such as:Secondary services may be needed to$40 BEMER
    Acupuncture, BEMER, Hydromassage, Ionic, FootBath, etcget a complete result clinically,$20 Hydromassage
    Consultationsbut are not covered.$45 Ionic FootBath
    SupplementsIn most cases your personal health$ - Consultations and Supplements,
    vary in cost
    Therapeutic Massage is limited in coverageinsurance will not cover either.$89 60 Minute Massage/Acupuncture


    Our office has been notified that your care may not be reimbursed, or is likely to be, or has been, denied by your Payer. How would you like to handle care at our office? Please choose one:


    Option 1 -- Continue treating according to the Office's recommendations and accept full financial responsibility for care.

    I want to continue receiving care from the Office according to the Office's recommendations. I understand that any or all care I receive or have received may not be reimbursed, or is likely to be denied, by the Payer either as not causally-related to the accident, not medically necessary, or otherwise not reimbursable ("Initial Assessment"). I agree with this Initial Assessment and I recognize that I retain full financial responsibility for all such services from the applicable date. I understand that I am waiving any protections that I may have from balance billing of the Office's Charges under any applicable law. If I disagree with any adverse determination by a Payer and wish to challenge its findings, I understand that I may have a right, and that it is my sole responsibility at such point to pursue any appeal rights I may against the Payer on my own initiative, either through my attorney or otherwise. I agree, however, that the Office retains all other rights which it may have under the Assignment & Lien Document which I previously executed. I understand and agree that any subsequent settlement, judgment, verdict, or administrative finding, inconsistent with the Initial Assessment, shall not supersede my Assessment or the terms of this notice.


    Option 2 -- Continue treating according to the Office's recommendations and accept full financial responsibility for care, but do not provide supportive services that are historically not likely to be reimbursed.

    I still accept full financial responsibility for the services likely to be covered.


    Option 3 -- I wish to discontinue care

    I am choosing to self-discharge from the Office's care in light of the above. I understand that by choosing to self-discharge from care, I agree to accept full responsibility of any negative outcomes associated with premature discontinuation of the Office's recommended care plan and shall further hold the Office harmless for my decision.


    IMPORTANT: I AM MAKING THIS ELECTION VOLUNTARILY AND ALSO WITH FULL PRIOR KNOWLEDGE OF ITS TERMS. THIS ELECTION WILL REMAIN IN EFFECT UNTIL A NEW ELECTION IS SIGNED WITH THE OFFICE'S CONSENT. THIS ELECTION SUPERSEDES ANY PRIOR ELECTION.

    The next page is a Letter of Protection for the patient to sign.
    We will obtain the attorney signature if relevant. This form is an agreement that if the patient and/or attorney receives a payment as part of any settlement from the insurances (as part of services rendered here and are not yet paid), the patient and/or attorney agree to forward our portion of payment in a timely manner.
    NEWTON CHIROPRACTIC & WELLNESS CENTRE
    LETTER OF PROTECTION

    I/We ("we") the undersigned patient and attorney, will protect the interests of NEWTON CHIROPRACTIC & WELLNESS CENTRE ("the Office") out of the proceeds of any settlement, judgment, or verdict, as well as out of any no-fault proceeds, relating to the accident listed above.


    By "interests," we mean any outstanding balance owed to the Office by me, the Patient, for any Charges incurred at the Office as defined by the Office's documents.


    This letter of protection shall not be modified or revoked without the written consent of the Office. This letter of protection shall not be exclusive of any other security interests or rights, if any, which the Office may have.

    Patient's Signature
    Attorney's Signature

    Please Be Advised:

    If You Are Unrepresented by Legal Counsel, Be on the Look-Out for Low Settlement Offers


    PLEASE BE ADVISED that as you attempt to negotiate the settlement of your case with the other party's insurance company (or your uninsured motorist coverage), the adjuster may make an offer that seems unfairly low and that may not even cover the amount of your medical / chiropractic bills. For this reason, we recommend that you consider retaining legal counsel to protect your rights.


    For instance, the adjuster may persuasively attempt to convince you that for a number of reasons the offer will not go any higher and you may be given an ultimatum of "take it or leave it." This is just one of the many reasons why we recommend you consider retaining legal counsel to protect your interests. In the absence of representation, the adjuster's offer may simply be what the adjuster thinks he or she can get you to take versus what is fair and equitable.


    In fact, in some cases, we have heard of adjusters telling unrepresented patients that the health care bills were unreasonably high and that not all of the treatment was necessary. BEWARE OF THESE AND OTHER LIKE PRACTICES. Rest assured that the treatment that was provided to you at our Office for your injuries was medically necessary and that the amount of our charges are well within the usual and customary range for this region of the country.


    Whenever this office is notified that the full amount of our bills may not be covered by the settlement amount, on our own behalf, not representing any patient, our office demands to see a PROPER WRITTEN REVIEW PERFORMED BY AN APPROPRIATE HEALTH CARE PROVIDER who is trained and experienced in the care you received, who can understand what the care was about, and who can provide a more fair, less biased, opinion on the matter.


    It should be clear to you based on your previous acknowledgment that it is your responsibility to pay your outstanding balance (or make sure that we are paid) at our Office, regardless of the amount of your settlement with the insurance company.


    THE TIME TO HAVE A PROPER MEDICAL NECESSITY REVIEW PERFORMED IS BEFORE SETTLEMENT IS COMPLETED, AND NOT AFTER. AGAIN, CONSIDER RETAINING LEGAL COUNSEL TO PROTECT YOUR RIGHTS.


    Thank you!

    This notice does not constitute legal advice and does not establish an attorney-client relationship. If you have questions of a legal nature, you should contact an attorney at law.

    Thank you for taking the time to fill out this form.

    Office Hours

    Monday:

    9:45 am

    8:00 pm

    Tuesday:

    7:45 am

    8:00 pm

    Wednesday:

    7:45 am

    8:00 pm

    Thursday:

    7:45 am

    8:00 pm

    Friday:

    7:45 am

    7:15 pm

    Saturday:

    8:30 am

    3:00 pm

    Sunday:

    10:00 am

    5:00 pm

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