By Typing My Name On This Form I Indicate My Agreement to Abide by the Office Policy of Frank Bendiks, DC, PC
Patient Name (required)
Helping Patients With Their Bills:
We turn away no patient in need of medical care. We offer financial assistance to those patients in need. Just ask us. We will help you.
HIPPA "Patient Rights Act" of 1996:
This act passed by the Federal Government allows for certain rights to the patient. Among these are the right to review the practice's "Notice of Privacy" policy, as well as other rights, such as the right to have medical records protected and kept private. The law also provides rights to the healthcare facility and physician. The full documentation and compliance package encompasses some 40+ pages. In order to simplify paperwork that you need to read and sign we have ancluded eight (8) different forms on this one (1) page. We have made great effort to make it easier on the patient wishing to seek medical care, without being overwhelmed with paperwork.
I have requested medical services from Frank Bendiks, DC, PC on behalf of myself and/or dependents and understand that by making this request, I become financially responsible for any charges incurred in the course of treatment. Necessary insurance forms will be completed to help me file my insurance, but I understand that I am still responsible for any amount not covered by my insurance.
Assignment of Benefits:
I assign all medical insurance benefits to which I am entitled. I authorize and direct my insurance carrier, including Medicare and auto or home insurance payments to be made directly to Frank Bendiks, DC, PC for medical services rendered to me and/or my dependents.
Authorization to Release Information:
I authorize Frank Bendiks, DC, PC to: 1) release any information necessary to insurance carriers regarding my illness and treatment; 2) process insurance claims generated in the course of treatment; 3) allow a photocopy of my signature and typed name, at the top of this form, to be used to process claims and 4) a photocopy of this form is to be considered as valid as the original.
Direct Payment to Facility/Physician:
If my insurance policy prevents direct payment to the physician, I instruct the insurance carrier to make the check payable to me and mailed to the following address: Frank Bendiks, DC, PC; 1112 S. Washington St., Suite 204; Naperville IL 60540-7960
Limited Medical Power of Attorney:
Occasionally, insurance carriers mistakenly make payment checks out in the name of the patient instead of correctly making them out to the physician. I authorize Frank Bendiks, DC, PC to sign my name to to the check, so that it may be properly deposited and credited to my account.
Letter of Protection:
For patients who have attorney representation. I direct my attorney to pay my outstanding balance due out of my settlement and to protect such balance. Frank Bendiks, DC, PC will wait no more than ninety (90) days following my discharge from care for settlement and payment of my balance.
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