Insurance verification and financial policy
I authorize New Life Health & Wellness to verify coverage, obtain claim information, communicate with insurers/adjusters, submit claims and supporting documentation, and bill applicable PIP, MedPay, health insurance or other responsible coverage. I understand verification is not a guarantee of payment; I remain responsible for lawful charges not paid, except where prohibited by law or contract.
Assignment of PIP benefits / direction to pay
In consideration of services rendered or to be rendered, I assign to New Life Health & Wellness, to the extent permitted by Florida law and my policy, rights to payment of PIP and applicable automobile medical benefits for covered clinic services. I direct the insurer to pay the clinic directly and authorize the clinic to submit claims, receive payment and EOBs, request claim information, submit corrected claims, and pursue lawful remedies for unpaid or underpaid covered charges. This does not assign my personal-injury tort claim or unrelated settlement rights and does not guarantee coverage or payment.
Health and claim information authorization
I authorize the clinic and its workforce/business associates, as permitted by law, to obtain from and disclose to auto/PIP/MedPay insurers, health insurers, attorneys, EMS/hospitals, treating providers, imaging facilities, pharmacies and employers information reasonably necessary for treatment, payment, operations and this motor-vehicle claim. This may include history, findings, diagnoses, plans, notes, imaging, billing, EOBs, accident information and work restrictions. This authorization expires one year from signature or at the conclusion of the claim/treatment episode unless revoked in writing, except to the extent already relied upon.
Chiropractic examination and treatment consent
I consent to chiropractic examination and clinically indicated care, which may include spinal/extremity manipulation or mobilization, manual therapy, therapeutic exercise, neuromuscular re-education, traction and physiotherapeutic modalities. Temporary soreness, stiffness, fatigue or symptom aggravation may occur. Less common risks include sprain/strain, fracture in susceptible individuals, disc or nerve aggravation and other injury. Cervical manipulation has been associated with rare serious neurologic or vascular events. I may ask questions, decline a procedure or withdraw consent at any time. No outcome, care duration or insurance payment is guaranteed.
Privacy, accuracy and final certification
I acknowledge that I have been offered access to the clinic Notice of Privacy Practices. I certify that the demographic, accident, medical, insurance, employment and attorney information supplied is true and complete to the best of my knowledge; that I was not promised money, gifts or improper inducements to seek treatment or make a claim; and that I have reviewed this intake and had an opportunity to ask questions.
