Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.
In consideration of medical serviced provided to me by Brown Family Chiropractic, P. I Irrevocably assign to BFC Thereafter referred to as "Assignee" any and all insurance benefits available to me including but not limited to health insurance.
Personal Injury Protection PIP benefits, Med Pay benefits, uninsured motorist benefits, underinsured motorist benefits, optional or compulsory bodily injury coverage, general liability coverage and or worker's compensation benefits to the extent of any bills for medical services provided to me by Assignee.
In the event there is no such insurance benefits available to cover the Assignee's bills, I further assign to the extent necessary to pay in full the bills of the Assignee, the proceeds of any Judgement, arbitration award or settlement. In the event the bills of the Assignee are not paid in full by insurance benefits, judgement, arbitration, award, or settlement, I personally agree to pay any outstanding balances owed to the Assignee.
The irrevocable Assignment shall in no way limit or abrogate my right to sue any applicable insurer in the event the insurer denies coverage for the Assignee's bills. By the way of the Assignment, I hereby instruct my attorney and or an applicable insurer to pay the medical bills covered by this agreement directly to Brown Family Chiropractic, P.
