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ESTE ACUERDO DE DERECHO DE RETENCION DE PRÁCTICA MÉDICA (el "Acuerdo") se celebra por el presente por y entre:

Nombre del paciente:*
(“Paciente”),
Abogado:*
(“Abogado”) y and GASpineOrtho Orthopaedics Spine & Neurology (“Proveedor”).

POR CUANTO, el Paciente resultó lesionado en un accidente o incidente y busca atención médica/diagnóstica del Proveedor para sus lesiones; y

POR CUANTO, el Abogado representa al Paciente en cualquier reclamo o demanda (“Acción Legal”) para recuperar danos que surjan a partir del accidente o incidente, incluidos gastos médicos o diagnósticos; y POR CUANTO, el Proveedor haya aceptado brindar tratamiento al Paciente sin requerir pago en el momento de prestar el servicio; DE AHORA EN ADELANTE, en consideración de las premisas, los convenios mutuos contenidos en este documento, y otra consideración buena y valiosa, cuyo recibo y suficiencia se reconocen por este medio, las partes acuerdan lo siguiente:

  1. El Paciente reconoce que de acuerdo con la Ley de Portabilidad y Responsabilidad de la Información de Salud de 1996 ("HIPAA"), la información medica del Paciente relacionada con la Acción Legal puede ser compartida para expedir el tratamiento medico del Paciente. El Paciente autoriza al Proveedor de divulgar cualquier información necesaria para el Abogado para para llevar a cabo la acción legal, incluida, entre otras, la información (incluida información de cobro) acerca de examinación, tratamiento, procedimiento y otros servicios brindados por el Proveedor. El Paciente autoriza al abogado a asegurar, divulgar dicha información medica con individuos y entidades necesarias para llevar a cabo la Acción Legal, y el Paciente acepta que las examinaciones, diagnósticos, tratamientos médicos, grabaciones y reportes sean compartidos con entidades involucradas en la Acción Legal. El Abogado reconoce que ha obtenido una Divulgación de información médica del paciente para fines de comunicaciones con respecto a la información médica del paciente. El Paciente autoriza al Abogado de mantener informado al Proveedor sobre el progreso de la Acción Legal a intervalos razonables.
  2. Por la presente, el Paciente otorga al Proveedor un derecho de retención sobre el producto de cualquier acuerdo, juicio o veredicto en la Acción Legal que un tercero pueda pagar al Paciente o al Abogado como compensación por las lesiones por las cuales los servicios de atención médica están sujetos al C.G.S. 44-49 et. seq. El Paciente notificara al Abogado que le sigue dando al Proveedor un derecho de retención en estos beneficios o procedimientos de negociación, y el Paciente autoriza y ordena al Abogado que retenga dichos fondos de cualquier acuerdo, veredicto o juicio que se dicte en la Acción Legal y pague al Proveedor directamente de dichos ingresos cualquier suma adeudada por los servicios médicos prestados al Paciente. Este derecho de retención es irrevocable y solo puede ser satisfecho por el pago completo del monto por los servicios médicos, a menos que el Proveedor acepte lo contrario por escrito. El Paciente entiende que cualquier negociación, veredicto o juicio no puede ser desembolsado al Paciente sin primero satisfacer este derecho de retención.
  3. En caso de que surja una disputa con respecto al pago de los cargos del Proveedor, el Paciente autoriza e indica al Abogado que retenga en depósito todo el dinero suficiente para satisfacer este derecho de retención hasta que la disputa pueda resolverse. El paciente y el abogado reconocen que sería una violación de los deberes éticos del abogado para desembolsar los fondos en disputa antes de la resolución de la disputa del derecho de retención.
  4. El Paciente entiende y acepta que a pesar de que se haya dado este derecho de retención, el Paciente sigue siendo personalmente responsable por el pago completo del monto del Proveedor por los servicios brindados, incluido los gasto de servicios en las instalaciones del Proveedor (exámenes y visitas de oficina, Rayos X, ultrasonidos, inyecciones, suplementos, medicamento a través de Comprehensive Rx o Meds Management Group) y gastos del Proveedor (servicios quirúrgicos) proporcionados en las instalaciones. El Paciente es únicamente responsable de hacer los arreglos necesarios de pago de costos al seguro medico, por ejemplo. El Paciente reconoce que esta obligación no depende del resultado del caso en la corte del Paciente. EL Proveedor y el Paciente aceptan que en el evento de ser necesario el en forzamiento de este consentimiento en una corte, además de todos los daños y costos, la parte vencedora tendrá derecho a honorarios razonables de abogado por un monto del 25 % del monto en cuestión.
  5. El Proveedor acepta esperar al pago del Paciente por los servicios y gastos hasta que la Acción Legal sea resuelta por negociación, juicio o veredicto, excepto en la medida en que el pago esté disponible a través del seguro médico del Paciente. El Paciente y el Abogado reconocen expresamente la validez y aplicabilidad del derecho de retención del Proveedor a partir de la fecha en que comienza el tratamiento del Paciente por parte del Proveedor y aceptan expresamente estar sujetos a los términos de este Acuerdo. El Paciente y el Abogado reconocen expresamente que este Acuerdo constituye una notificación real de los registros médicos y las facturas del Proveedor, y el Paciente renuncia al derecho de hacer valer cualquier defensa a la validez y exigibilidad del derecho de retención del Proveedor basado en la falla del Proveedor para perfeccionar el derecho de retención de acuerdo con el C.G.S. 44-49 et. seq. Acción Legal de acuerdo con los requisitos de N.C.G.S. 44-49 et. seq. La partes aceptan que una fotocopia de este Acuerdo sea considerada notificación valida del derecho de retención.

Consentimiento del Paciente

El Paciente reconoce que este Acuerdo debe estar firmado por mi antes de que se proporcione cualquier servicio medico para el Paciente por parte del Proveedor

Nombre del paciente:*
MM slash DD slash YYYY
AL ABOGADO DEL PACIENTE: Firme, ponga la fecha y devuelva una copia de este Acuerdo al Proveedor. Guarde una copia para su registro.
Nombre del Abogado:
MM slash DD slash YYYY

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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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