Consent of Professional Services and Release of Information
I herby authorize the doctor and whomever they may designate as the assistants to administer: treatment, physical examination, X-Ray studies, laboratory procedures, chiropractic care or any clinic service he/she deems necessary in my case. I further authorize him/her to disclose all or any part of my (patient’s) record to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member or employer of the patient for all or any of the clinic’s charge, including, and not limited to: hospitals, medical service companies, insurance companies, worker compensation carriers, welfare funds, or the patients employer.
Assignment of Health Benefits
The parties appearing below hereby agree to the following conditions, covenants and terms regarding the assignment of health benefits appearing in the policy that has been presented to this office. I hereafter referred to as “Patient”, understand and voluntarily agree to assign all applicable health provisions pertaining to payments or benefits appearing in my insurance policy in consideration for treatment rendered by Dr. R. Scott Farley, referred to as “Doctor”. The patient, the policy holder, requests, orders and directs the insurance company to pay Dr. R. Scott Farley directly to his office at 3314 East 46th Street or if my current policy prohibits direct payment to the doctor, I herby understand that it is my responsibility to direct all payments to the address as follows: 3314 East 46th Street Tulsa, OK 74135 Suite 101 for the sum due to the Doctor for treatment rendered. The patient gives the doctor exclusive right to secure the funds assigned the patient, including the right of securing counsel to represent the Doctor in the collecting all sums due for treatment rendered. The Doctor and Patient hereby enter into the assignment of benefits freely and voluntarily and evidenced by the signatures appearing below: that Patient and Doctor warrant that they have read this assignment of benefits and that each understand the legal effect of the same, and agree that each shall be bound by the covenant, terms and conditions appearing herein. A photocopy of this Assignment shall be considered as effective and valid as the original.
Clinical summary Report (CCR): I understand that a clinical summary report is created after each visit for the purpose of EHR and is available for my review. At this time, I am asking Farley Chiropractic to save these electronically for me and not print them out each visit. I understand, upon request, these reports are available to be printed or emailed to me for review.