Patient Payments
Auto Accident Information Form
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PATIENT INFORMATION

Patient Name
Address

INSURANCE INFORMATION

Address
Law Firm's Address

I understand that Family Practice Associates has a conflict of interest with the law firm of Roeberg, Moore and Friedman. If I choose this firm, I must find another physician outside of Family Practice Associates to manage my care for this accident.

If I choose any of these attorneys, I must find another physician outside of Family Practice Associates to manage my workman’s compensation injuries.

AUTHORIZATION TO RELEASE INFORMATION AND TO PAY BENEFITS DIRECTLY TO FAMIY PRACTICE ASSOCIATES, P.A.

I hereby authorize the release of my records from the files of Family Practice Associates:

Checkboxes

Assignment and Release: I hereby authorize my insurance benefits be paid directly to Family Practice Associates, P.A. for any and all medical /surgical procedures performed or services rendered in this matter. I am financially responsible for non-covered services.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

SETTLEMENT DISBURSEMENT AUTHORIZATION

I, the undersigned, hereby authorize my law firm to pay any outstanding medical claims as a result of my accident to be paid out of my settlement.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

ATTORNEY ATTESTATION

This statement will serve as confirmation that the balance de Family Practice Associates, P.A. will be protected in the event of settlement of this claim.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

LETTER OF AGREEMENT BETWEEN FAMILY PRACTICE ASSOCIATES (FPA) AND AUTO ACCIDENT CLAIMANTS / PATIENTS

I understand that there may be a deductible under my automobile insurance and that I am responsible for payment of the deductible. I plan to make payments toward the deductible each time I am seen in the office even if I have selected an attorney to represent my interest in regard to my accident.
I will complete the Personal Injury Protection (PIP) application in order to start the claim process with my insurance company promptly.
I know that Family Practice Associates, P.A. has requested a letter of protection from my attorney and I will make sure that FPA receives it.
If I have an Independent Medical Examination (IME) which results in a denial of my claim and FPA DOES NOT have a letter of protection from my attorney, I understand that I am personally responsible for the bills and will make regular payments.
If the automobile insurance DOES NOT cover the full fees for services provided by Family Practice Associates, I understand that I am responsible for the balance.
Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.

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