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Brief Description of the Accident Were you wearing a seat belt? Did you go to the hospital?
If Yes, Name of the Hospital Have you lost time from work?
Primary Care Physician
Physician Phone Have you been involved in any previous accidents?
If yes, what year?
If yes, explain
Present Complaints (Please be specific) Legal & Insurance Information
Address Auto Insurance Information
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Relation to the patient Have you been solicited by an individual concerning this accident?
If yes, please explain
Mauricio Chiropractic Location * Mauricio Chiropractic Downtown, 205 East Colonial Drive Orlando, FL 32801 Mauricio Chiropractic Dr. Phillips, 7601 Conroy-Windemere Road #204 Orlando, FL 32835 Mauricio Chiropractic Conway, 4747 S. Conway Road Ste A Orlando, FL 32812 Mauricio Chiropractic Winter Park, 1810 Semoran Blvd Ste 104 Winter Park, FL 32792 Mauricio Chiropractic Pine Hills, 1050 Pine Hills Road Orlando, FL 32808 Mauricio Chiropractic E. Colonial, 12278 E. Colonial Dr. Ste 700 Orlando, FL 32826 Mauricio Chiropractic South OBT, 12720 S. Orange Blossom Trail #20 Orlando, FL 32837 Mauricio Chiropractic Poinciana, 860 Towne Center Drive Kissimmee, FL 34759
I hereby authorize any physical, hospital, pharmacy, insurance company, employer, or organization to release any and all medical information history, records diagnosis, records or x-rays in your possession concerning the undersigned to Mauricio Chiropractic, LLC, or treating doctor. A photocopy of this authorization shall be valid as the original.
AUTHORIZATION AND ASSIGNMENT: I hereby authorize my insurance company to pay direct to Mauricio Chiropractic, LLC the expenses benefits allowable, and otherwise payable to me under my current insurance policy, as payment toward the total charges for professional services rendered. This payment shall not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance for said professional services charges over and above this insurance payment. DOCTORS LIEN: I do hereby authorize the above doctor to furnish you, my attorney, with a full report of his examination diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was involved. I hereby authorize and direct you, my attorney, to pay directly to paid doctor such sums may be due and owing him for medical services rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect said doctor. And I hereby further give a lien on my case to said doctor against any and all proceeds of any settlement, judgment, or verdict which may be paid to you, my attorney, or myself as a result of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to paid doctor for all medical bills submitted by him for services rendered to me and that this agreement is made solely for paid doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover paid fee.
I have read the above and authorize my consent *