New Patient Form: Authorization to Release Medical Records

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THIS PHYSICIAN PRACTICE LIEN AGREEMENT (the “Agreement”) is hereby entered into by and among:
("Patient"), (“Attorney”) and Erik T Bendiks, MDPC
WHEREAS, Patient was injured in an accident or incident and is seeking medical/diagnostic care from Provider for his/her injuries; and
WHEREAS, Attorney represents Patient in a claim or lawsuit (the “Legal Action”) to recover damages arising
from the accident or incident, including medical/diagnostic expenses; and
WHEREAS, Provider has agreed to render treatment to Patient without requiring payment at the time of rendering services;
NOW THEREFORE, in consideration of the premises, the mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
1. Patient acknowledges that, in accordance with the Health Information Portability and Accountability Act of 1996 ("HIPAA"), Patient's medical information relating to the Legal Action may be shared to manage and expedite Patient's medical treatment. Patient authorizes Provider to release any information needed by Attorney to pursue the Legal Action, including without limitation information (including billing information) regarding the examination, treatment, procedures and services rendered by Provider. Patient authorizes Attorney to secure, release, and disclose such medical treatment information with individuals and entities as deemed necessary to pursue the Legal Action, and Patient further agrees that examinations, diagnoses, medical treatments, films and reports can be shared with necessary parties involved in the Legal Action. Attorney acknowledges that Attorney has obtained a Release of Medical Information from Patient for purposes of communications regarding Patient's medical information. Patient expressly authorizes Attorney to keep Provider advised of the progress of the Legal Action at reasonable intervals.
2. Patient hereby grants to Provider a lien on the proceeds of any settlement, judgment or verdict in the Legal Action which may be paid to Patient or to Attorney. Patient hereby notifies Attorney that Patient is giving Provider a lien on these benefits or settlement proceeds, and Patient hereby authorizes and directs Attorney to withhold such funds from any settlement, verdict or judgment that is rendered in the Legal Action and pay Provider directly from any such proceeds any sums due for medical services rendered to Patient. This lien is irrevocable and can only be satisfied by full payment of all sums due for medical services rendered, unless Provider expressly agrees otherwise in writing. Patient understands that any settlement, verdict or judgment proceeds cannot be disbursed to Patient without first satisfying this lien.
3. Should a dispute arise regarding payment of Provider’s charges, Patient authorizes and directs Attorney to hold in escrow all monies sufficient to satisfy this lien until the dispute can be resolved. Patient and Attorney acknowledge that it would be a violation of Attorney’s ethical duties to disburse the disputed funds prior to resolution of the lien dispute.
4. Patient understands and agrees that even though this lien has been given, Patient remains personally responsible for payment in full of Provider’s fees for all services rendered, including without limitation fees for services provided at Provider’s office locations (e.g., exams and office visits, x-rays, injections, DME, PT, supplies, medications and fees for Provider’s services (e.g., surgical services) provided at any other facility. Patient is solely responsible for making appropriate arrangements for payment of such fees, including but not limited to insurance benefits. Patient acknowledges that this obligation to pay Provider’s fees is not dependent on the outcome of Patient’s court case. Provider and Patient agree that in the event it is necessary to enforce this Agreement in a court of law, then in addition to all damages and costs, the prevailing party shall be entitled to reasonable attorney's fees in the amount of 25% of the amount at issue.
5. Provider hereby agrees to await Patient’s payment of Provider’s fees until the Legal Action is resolved by settlement,
judgment or verdict, except to the extent that payment is available from Patient’s medical insurance.
6. Patient and Attorney hereby expressly acknowledge the validity and enforceability of Provider’s lien as of the date Provider’s treatment of Patient commences and expressly agree to be bound by the terms of this Agreement. Patient and Attorney expressly acknowledge that this Agreement constitutes actual notice of Provider’s lien pursuant to OCGA §44-14-471(b), and Patient waives the right to assert any defense to the validity and enforceability of Provider’s lien based on Provider’s failure to perfect the lien in accordance with OCGA §44-14-471(a). Patient hereby directs and authorizes Attorney to provide actual notice of Provider’s lien to all parties involved in the Legal Action in accordance with the requirements of OCGA §44-14-471(b), and Attorney agrees to be responsible for providing such notice. The parties agree that a photocopy of this Agreement shall be considered as valid as the original.
7. If Patient should retain new legal counsel, Attorney and Patient agree to notify Provider immediately upon such change. Patient shall direct such new legal counsel to execute another copy of this Agreement and deliver same to Provider.
8. This Agreement cannot be modified, amended or revoked by any party without the express written consent of all parties.
9. If the net recovery is less than the outstanding charges owed to all health care providers covered by letters of protection or lien rights, net settlement proceeds will be distributed on a pro rata basis or as required by legal priority under Georgia or other applicable law.

Acknowledgement by Patient
I acknowledge that this Agreement must be signed by myself and by my attorney before any medical services will be provided to me by Provider. I have been advised that if my attorney does not wish to cooperate in protecting Provider’s interest, Provider will await payment and may declare the entire balance due and payable.
(Patient’s Signature)

Date

Patient’s Printed Name:

TO PATIENT’S ATTORNEY: Please sign, date and return one copy of this Agreement to Erik Thor Bendiks MD PC DBA Georgia Spine and Orthopaedics. Keep one copy for your records.
Acknowledgement by Attorney
I acknowledge that this Agreement must be signed by representing attorney and patient before any medical services will be provided to me by Provider. I understand that if I do not wish to cooperate in protecting Provider’s interest, Provider will await payment and may declare the entire balance due and payable.
(Attorney’s Signature)

Date

Attorney’s Printed Name:

Attorney’s Address (Street, City, State and Zip Code)

New Patient Packet
PERSONAL INFORMATION

Patient Name: Date of Birth: Home Address: City: State:
Zip: Home Phone: Cell: Work: ext.
Email :
Sex: [radio* radio-350 "Male" "Female"] Marital Status: Work Status:
Employer: Occupation:
Employer Address:
Emergency Contact Name:
Emergency Contact Phone:

INSURANCE INFORMATION
Primary Insurance: Policy Holder:
Relationship to Policy Holder: Policy Holder DOB:
Secondary Insurance: Policy Holder:
Relationship to Policy Holder: Policy Holder DOB:

HIPAA ACKNOWLEDGEMENT

In accordance with the HIPAA of 1996, I acknowledge that I was given access to and/or offered a copy of the Notice of Privacy Practices for ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS.

Patient Name: Legal Guardian:
Signature of Patient over 18 years old or Legal Guardian:

Date:

CONSENT For TREATMENT and ASSIGNMENT of BENEFITS
I consent to the provision of treatment that may include diagnostic procedures and medical treatment by ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS. I understand special consent forms may need to be signed for specific procedures. If I have a religious objection to specific care to be provided, I may ask ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS not to provide such care.

I consent to treatment by ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS with the understanding that I will furnish accurate information regarding my injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. My non-compliance with the plan of treatment may result in the refusal of further care and discharge from ERIK T BENDIKS MD PC d/b/a/ GEORGIA SPINE & ORTHOPAEDICS.

I acknowledge that no guarantees have been given to me as to the outcome of any examination or treatment. I hereby authorize Georgia Spine & Orthopaedics to leave medical information pertaining to my care by the following

I understand that my ability to receive medical care is not affected by the signing this form. I have the right to receive a copy of this form after it is signed. I may revoke this consent at any time in writing but revoking consent will not affect any actions prior to receiving the revocation.

This consent shall remain in effect until such written request to revoke is received.

I hereby give permission to allow GSO to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give GSO permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS/HIV and medications used to treat mental health issues.
Assignment of Benefits: Patient herby assigns and authorizes payment directly to GSO of
any private healthcare insurance, (ii) medical payment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resulting from the liability of a third party, payable by any party, organization, attorney, etc., to or for Patient, unless and until Patient’s account with GSO for the services or series of related services provided by the GSO Providers (collectively, the “Services”) is paid in full, upon discharge or completion of the Services. Patient herby authorizes GSO to apply and file for all such payments referenced herein on behalf of Patient, and direct that such payments be made directly to GSO.
Payment Responsibility: Patient understands that he/she is responsible for any portion of the GSO invoice(s) for Services that remains outstanding. Patient agrees to execute any necessary documents to direct all third-party benefits and other payments for Services to GSO.

THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ/ COMPLETED FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL ERIK T BENDIKS MD PC PROVIDERS.

Patient Name: Legal Guardian (if applicable):
Signature of Patient over 18 years old or Legal Guardian:

Date:
CONSENT TO MAIL MEDICATIONS TO MY HOME
GENERAL INFORMATION
Our medical practice is licensed to dispense certain medications (“Your Medications”). As a convenience to you, we are willing to mail you refills of Your Medications to your home address via First-Class Mail. There is a risk, however, that (i) someone may steal Your Medications out of your mailbox, (ii) a family member or other person authorized to collect the mail from your mailbox may wrongfully take Your Medications, (iii) Your Medications may get lost or stolen in transit from our office to your mailbox, or (iv) Your Medications may be delivered to the wrong address. Additionally, a collateral risk of mailing Your Medications is that your Protected Health Information (PHI) is discovered by an unauthorized party. Knowing these risks and accepting the liability and responsibility for same, if you still want Your Medications mailed to you, then you must complete this form to show that you have accepted this risk. Our office is not responsible if sending Your Medications results in an unauthorized person seeing your PHI or obtaining Your Medications.

ACCEPTANCE, CONSENT, AND WAIVER
This form gives you the facts about receiving Your Medications by mail. By signing this form, you confirm that you have read, understand, and agree with these terms.

I agree to allow Georgia Spine and Orthopedics of Atlanta and/or Surgery Center of Roswell (collectively, “GSO”) to mail my prescriptions directly to my address as listed below. This mailing will include my PHI, such as my name and the medication that I am taking and may include other sensitive facts about my health. I understand that if another person accesses my prescription, that person will see my PHI. If I do not want to accept the risk that someone may take my prescription and/or access my PHI, I should not agree to allow GSO to mail my prescriptions to me.

I accept these risks and agree that GSO may mail my prescriptions to me via First-Class Mail. I agree to inform GSO immediately if my address changes. I will not hold GSO responsible if my PHI is seen by an unauthorized person or my medications are taken/obtained by an unauthorized party. I RELEASE, WAIVE, DISCHARGE AND PROMISE NOT TO SUE OR BRING ANY CLAIM OF ANY TYPE AGAINST GSO FOR LOSS, DAMAGE, INJURY, OR LIABILITY RELATING TO THE MAILING OF MY MEDICATIONS TO MY DESIGNATED ADDRESS.

My designated address and the address where I hereby request GSO to mail my prescriptions is:

PATIENT ACKNOWLEDGMENT
This form gives you the facts about and risks involved in receiving Your Medications by mail. By signing this form, you confirm that you have read, understand, and agree with these Terms of Use for receiving Your Medications by mail.
My signature below indicates that I freely consent to receive my medications from GSO by mail to the address that I provided herein. I also confirm by signing below that:
• I have been able to ask any questions
• All my questions have been answered
• No guarantees have been made
• I agree to the terms as noted above
By my signature below, I acknowledge having the choice between obtaining my medications from GSO or at a pharmacy of my choice and authorize Comprehensive RX the right to my medical records upon verbal or written request.

Patient Name and Date of Birth:

Signature of Participant or Responsible Party:

Date and Time: Relationship to Patient:

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