Assignment of Benefits / Assignment of Cause of Action / Contractual Lien
Our office will make every attempt to verify your policy benefits. however, this office and your insurance DOES NOT guarantee a quote of benefits for payment of services provided. Should your insurance provide Chiropractic benefits, your insurance will be filed on a weekly basis as a courtesy to you. You will be responsible for your deductible and/or co-payment. Your insurance should pay within 45 days from the date in which it was filed. In the event that your insurance company does not pay a timely manner, you may be asked to contact your insurance carrier. If your Insurance company mails a check directly to you for our services, you must bring the misdirected check to our office within 48 hours.
Assignment of Rights and Conveyance of Lien Interest
I hereby execute and provide Irrevocable Lien Interest and Assignment of Proceeds to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services. make demand for payment, and prosecute and receive penalties, interest, court Ioos, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to cooperate, provide information as needed to assist in the prosecution of such claims for benefits upon request.
To any insurerce company providing benefits or settlement of a claim, you are instructed that pursuant to this Irrevocable Lien Interest and Assignment of Proceeds to pay the total dollar amount of all sums which I owe on account to the above named doctor and treating facility within 30 days following your receipt of medical bills submitted by the doctor and/or treating facility.
I instruct checks to be made payable to Island Chiropractic, payment to be sent to 14602 Compass, Suite B, Corpus Christi, Texas 78418. This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing fur attorney fees, 18% penalty, court cost, and intaest from judgment, upon violation. In the event my insurance settlement proceeds are paid directly to my attorney, I hereby irrevocably insuuct my attorney to withhold all such sums and amounts as are determined to be owed, due and payable on my account and remit payment of all such sums directly to the above named doctor and/or treating facility upon receipt of my settlement award(s).