PATIENT INTAKE FORM WITH AUTHORIZATION AND ASSIGNMENT

PATIENT INFORMATION
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SOCIAL HISTORY
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PAST MEDICAL HISTORY
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MEDICATION & ALLERGIES
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CHIEF COMPLAINT OR INJURY
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CHIEF COMPLAINT OR INJURY (Continued)
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AUTHORIZATION FOR HEALTH AND INSURANCE INFORMATION DISCLOSURE
(This form complies with the HIPPA Privacy Rule)
I understand that any disclosure of information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I need not sign this authorization to assure treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary. I understand that if I have any questions about disclosure of my health information I may contact the privacy officer at the facility listed above that is authorized to disclose this information and request a copy of this authorization.

I understand that my health record may include information pertaining to the treatment of drug and alcohol abuse, mental illness, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency (HIV), sexually transmitted diseases, tuberculosis or genetics.
ASSIGNMENT OF BENEFITS
1. I, the undersigned, hereafter referred to as “the patient”, do hereby assign all of my rights and interests to Oasis Medical Group, hereafter referred to as “the medical provider” to pursue and obtain payment from the above mentioned insurance carrier. This assignment shall include, but not limited to all rights available to me pursuant to the Personal Injury Protection Statues of New Jersey.

2. I, assign, to the medical provider, all my rights and benefits under the insurance contract for payment for services rendered to me. However, upon consent of both parties, same shall be revocable.

3. I, the patient, do hereby understand and acknowledge that if I willfully refuse to comply with reasonable requests of the insurance carrier, payment of my medical bills may be denied and I will be held responsible for same.

4. I, the patient, authorize my bodily injury attorney to pay directly to the medical provider any monies due on my account or have same deducted from any settlement made on my behalf.

5. I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health carrier and/or other insurance carrier fails to forward the check to the medical provider, I will endorse and sign the check to the medical provider within five (5) days of receipt of same.

6. I, the patient, do hereby acknowledge that I will not file suit and/or arbitration for the payment of the above provider’s medical bills unless I am requested to do so by the medical provider. I understand that the above referenced medical provider has an attorney and will collect payment on my behalf from the insurance carrier.

7. In the event that the insurance carrier and/or the vendor designated by the insurance carrier does not accept my assignment, or my assignment is challenged for being invalid, I execute this limited /special power of attorney and appoint and authorize the medical provider and counsel on behalf of the medical provider to file suit and/or arbitration directly against the carrier in my name and/or allow the medical provider to amend the law suit and/or arbitration to include my name.