AUTO LIABILITY Please Print: Name (First): (MI): (Last): Date: Address: City: State: Zip: Home Phone: Cell Phone:

Full text

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

AUTO LIABILITY Please Print:

Name (First):_________________________ (MI): ____ (Last): ____________________________________________Date:_______________ Address: _____________________________________City:_______________________________State:________ Zip: ____________________ Home Phone: ___________________ Cell Phone: ___________________________E-mail: __________________________________________ Driver’s License #:___________________________ Driver’s License State:___________ Occupation: ________________________________ DOB: ___________ Age: ______ Sex: ______ SSN#:______________ Employer/School: ___________________________________________ Business Phone#:___________________ Address:__________________________________________________________________________ If patient is a minor- Please complete:

Father’s Name: _________________________________________ Mother’s Name: ________________________________________________ Employer: ____________________________________________ Employer: _____________________________________________________ Position: ___________________________Phone:_____________ Position: ______________________________________Phone:___________ Please list the name of a person to contact in case of an emergency other than a spouse or parent:

Name: _____________________________________________________ Relationship: ___________________________ Phone: ____________ Address: __________________________________________ City: _______________________________State:________Zip:______________ Do you have an attorney? □Yes □No If yes, Name: ___________________________________________________ Phone#:

____________

Address: _____________________________________________________________________________________________________________

AUTO INSURANCE- Please have Insurance cards ready to be copied

Name of Company: __________________________________________________________ Phone: ___________________________________ Address: ____________________________________________ City: ______________________________ State: ________ Zip: ___________ Insured’s Full Name: _______________________________Insured’s SS#:_______________Insured’s DOB: __________________________ Policy#:____________________________________________Claim#:__________________________________________________________

PRIMARY INSURANCE-Please have Insurance cards ready to be copied

Name of Company: __________________________________________________________ Phone: ___________________________________ Address: ____________________________________________ City: _______________________________ State: ________Zip:___________ Insured’s Full Name: _______________________________ Is this an Employer’s Plan □Yes □No Insured’s SS#:_________________ ID#:____________________________________________ Group#____________________________________________________________ Insured’s DOB: _______________ Relationship to insured: (self, spouse, child, other):______________________________________________ AUTHORIZATION FOR TREATMENT/RELEASE OF INFORMATION/FINANCIAL AGREEMENT:

I give permission to administer treatment and perform tests as determined necessary by the physician in the diagnosis and treatment of my condition. Furthermore, I authorize the release of information relating to my medical treatment to my insurance company in order to process my claim services. I request that payments for insurance benefits made on my behalf, be paid directly to Howard J. Gelb, MD,PA. I assume full financial responsibility for all bills associated with this office and all tests, treatments, x-rays etc., that are not covered by my insurance. Payment is expected at the time of service, including all applicable co-payments and deductibles. I further understand that it is my responsibility to get authorization from my Primary Care Physician or Insurance Company (if required by the insurance company) prior to services being rendered. I understand that no guarantee or assurance has been made as to the results of the procedure or treatment and that it may not cure the condition. Should this become a collection problem, (the patient/client/debtor) assumes all costs of collection, including, but not limited to court costs, interest and legal fees.

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

LIABILITY PATIENT INFORMATION

Please Print:

Name (First) ____________________________ (Last) ___________________________________Date:___________

Age: _____ Ht: _______Wt: _______

Male

Female

Right Handed

Left Handed

Ambidextrous

Occupation:______________________________________________________________________________________________

How were you referred to our office?________________________________________________________________________

Who is your Primary Physician _____________________________________________ Phone #:___________________

HISTORY OF PRESENT ILLNESS

Describe the condition that brought you to this office:_______________________________________________________________

____________________________________________________________________________________________________________________

Is your injury:

Work Accident

Auto Accident

Slip & Fall

Date when Accident/Injury occurred: _________Where did Accident/Injury Occur? ___________________________

Description of Accident/Injury: ____________________________________________________________________________

_________________________________________________________________________________________________________

If this is an auto accident, were you thrown from the car?

Yes

No Did you lose consciousness?

Yes

No

Contributing events or cause for symptoms: __________________________________________________________________

Describe the severity and quality of pain: (sharp, dull, stabbing, etc.)________________________________________ Circle rating of 1-10 for severity of symptoms with 10 being the greatest: □1 □ 2 □3 □4 □5 □6 □7 □8 □9 □10

Frequency of symptoms:

Constant

Intermittent

Daily

Duration of symptoms:

Constant

Hrs

Mins

Seconds

Do symptoms include?

Swelling

Weakness

Numbness

Decreased Motion

Pins & Needle Sensation

Other____

If applicable, is the joint?

Popping

Locking

Clicking

Instability/Giving way

Other_________________________

What activities worsen your condition?

________________________________________________________________________________________________________

When do the symptoms occur?

Morning

Afternoon

Evening

During Exercise

After Exercise

Have you been previously treated for this accident/injury elsewhere? _____ If yes, by whom? ___________________

Past Treatment of your current problem:

Ice treatment

Heat Treatment

Physical Therapy

Rest (Length of Time)____

Injections (How Many?)_____

Medications

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TODAYS  DATE_______________      WHICH  PHYSICIAN  ARE  YOU  SEEING  TODAY?____________________________   NAME  (LAST)_______________________________  (FIRST)__________________________  (MI)________________   ADDRESS_________________________________        CITY_________________________  STATE____  ZIP__________  

HOME  PHONE  _____________    CELL  PHONE  _____________     WORK  PHONE  _____________  

□MALE        □FEMALE              DATE  OF  BIRTH_____________  EMAIL_____________________________________  

SOCIAL  SECURITY  #_____________DRIVERS  LICENSE  #____________________DRIVERS  LICENSE  STATE_____  

LOCAL  PHARMACY  NAME__________________PHARMACY  PHONE        _____________    OCCUPATION:____________        

IN  CASE  OF  AN  EMERGENCY  PLEASE  CONTACT    

NAME  __________________________  RELATIONSHIP  ______________________  PHONE  _____________  

ADDRESS_________________________________        CITY_________________________  STATE____  ZIP__________  

PRIMARY  INSURANCE  -­‐  Please  have  Insurance  cards  ready  to  be  copied  

PRIMARY  INSURANCE  CARRIER_____________________________     PHONE  _____________  

POLICY  #________________GROUP  #______________  INSURED  DOB_____________  INSURED  SS#_____________   ADDRESS_______________________________  CITY  _______________________  STATE______  ZIP___________  

     SECONDARY  INSURANCE  

SECONDARY  INSURANCE  CARRIER___________________________     PHONE  _____________  

POLICY  #________________GROUP  #______________  INSURED  DOB_____________  INSURED  SS#_____________   ADDRESS_______________________________  CITY  ________________________STATE______  ZIP  ___________  

IF  THE  PATIENT  IS  A  MINOR  (UNDER  AGE  18)  -­‐  PLEASE  COMPLETE:  

FATHER’S  NAME  _______________________                    MOTHER’S  NAME______________________________  

EMPLOYER/POSITION  __________________                    EMPLOYER/POSITION  __________________________  

PHONE  _________________                      PHONE  _________________  

AUTHORIZATION  FOR  TREATMENT/RELEASEOF  INFORMATION/FINANCIAL  AGREEEMENT:  I  give  permission  to  administer  treatment  and  perform  tests  as  determined  by  the  physician   in  the  diagnosis  and  treatment  of  my  condition.  Furthermore,  I  authorize  the  release  of  information  relating  to  my  medical  treatment  to  my  insurance  company  in  order  to  process  my  claim   services.  I  request  that  payments  for  insurance  benefits  made  on  my  behalf,  be  paid  directly  to  Howard  J.  Gelb,  MD  PA.  I  assume  full  financial  responsibility  for  all  bills  associated  with  this  office   and  all  tests,  treatments,  x-­‐rays,  etc.  that  are  not  covered  by  my  insurance.  Payment  is  expected  at  the  time  of  service,  including  all  applicable  co-­‐payments  and  deductibles.  I  further  understand   that  it  is  my  responsibility  to  get  authorization  from  my  Primary  Care  Physician  or  Insurance  Company  (if  required  by  the  insurance  company)  prior  to  services  being  rendered.  I  understand  that   no  guarantee  or  assurance  has  been  made  as  to  the  results  of  the  procedure  or  treatment  and  that  it  may  not  cure  the  condition.  Should  this  become  a  collection  problem  the  patient  assumes  all   costs  of  coaction,  including,  but  not  limited  to  court  costs,  interest  and  legal  fees.  

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NAME:  ______________________________       DATE:____________________________  

PLEASE  CHECK  ONE:  

ETHNICITY:      □HISPANIC/LATINO     □NON  HISPANIC/NONLATINO     □OTHER  

RACE:  □AMERICAN  INDIAN  □  ASIAN  □BLACK/AFRICAN  AMERICAN  □NATIVE  HAWAIIAN  □WHITE    □OTHER______________   PRIMARY  LANGUAGE:  □ENGLISH    □SPANISH    □FRENCH    □ITALIAN      □GERMAN    □PORTUGUESE    □JAPANESE    □CHINESE    □RUSSIAN   □OTHER________________________  

MARITAL  STATUS:   □SINGLE     □MARRIED   □DIVORCED   □WIDOW   I  WAS  REFERRED  TO  THIS  OFFICE  BY  (PLEASE  CHECK  ONE):  

□ANOTHER  PHYSICIAN:  (DR.  ________________)   □ATTORNEY     □PHYSICALTHERAPIST          □OTHER____________   IS  YOUR  INJURY:    □WORK  ACCIDENT  □AUTO  ACCIDENT  □SLIP  &  FALL(LEGAL  CASE)  □SPORTS  REALTED     □OTHER  INJURY  

*PLEASE  SPECIFY  RIGHT  OR  LEFT  SIDE  AND  BODY  PART  OF  CONDITION  AND  BRIEFLY  DESCRIBE  WHAT  BROUGHT  YOU   INTO  THIS  OFFICE.    PLEASE  INCLUDE  DATE  OF  INJURY,  HOW,  WHEN  AND  WHERE  OCCURRED:    

 

____________________________________________________________________________________________________________  

DID  YOU  BRING  ANY  X-­‐RAYS,  MRIs,  CDs,  DVDs,  FILMS?          □Yes  □No            IF  YES,  PLEASE  SUPPLY  TO  OUR  STAFF.  

REVIEW  OF  SYSTEMS   CONSTITUTIONAL   □CHILLS   □FATIGUE   □FEVER     □WEIGHT  GAIN   □WEIGHT  LOSS       INTEGUMENTARY   □SKIN  LESIONS   □RASH  

□REDNESSS  OF  SKIN   □MOLES  

□DRY  OR  SCALY  SKIN     EYES,EARS,NOSE,THROAT   □BLURRRED  VISION   □CATARACTS   □CONTACT  LENS   □GLAUCOMA   □HEARING  LOSS   □DRY  MOUTH   □NASAL  CONGESTION   □SORE  THROAT   □TINNITUS   □LOOSE  TEETH             RESPIRATORY   □COUGH     □DIFFICULTY  BREATHING   □WHEEZING   □ASTHMA   □EMPHYSEMA   □BREATHING  TREATMENT     CARDIOVASCULAR   □CHEST  PAIN  

□CHORTNESS  OF  BREATH   □DYSPNEA  ON  EXERTION   □ANGINA  

□PALPITATIONS  

□INTERMITTENT  PAIN  IN    LEGS   □SWELLING/EDEMA     GASTROINTESTINAL   □DIARRHEA   □BLOODY  STOOL   □NAUSEA   □VOMITING   □ULCERS   □FOOD  INTOLERANCE         GENITOURINARY  

□BURNING  ON  URINATION   □BLOODY  URINE  

□DIFFICULTY  VOIDING   □HISTORY  OF  UTI     NEUROLOGICAL   □NUMBNESS   □SEIZURES   □BALANCE  PROBLEMS   □TINGLING   □DIZZINESS   □DIFFICULTY  WALKING   □FREQUENT  URINATION     PSYCHIATRIC   □DEPRESSION   □ANXIETY   □INSOMNIA   □ADDICTION   □DRUG  USE  

□HISTORY  OF  PSYCHIATRIC   PROBLEMS     HEMATOLOGY   □ABNORMAL  BLEEDING     □BLOOD  CLOTS     □AIDS   □CANCER   □SITE____________   MUSCULOSKELETAL  

(PLEASE  SPECIFY  RIGHT  OR  LEFT)  

□BACK  PAIN  

□DECREASED  RANGE  OF           MOTION  

□JOINT  PAIN   □JOINT  STIFFNESS   □SWELLING   □NECK  PAIN  

□ARM  PAIN        [□R  or  □L]   □SHOULDER  PAIN    [□R  or  □L]   □HIP  PAIN                    [□R  or  □L]   □KNEE  PAIN                  [□R  or  □L]   □ANKLE  PAIN            [□R  or  □L]   □FOOT    PAIN              [□R  or  □L]   □HEEL  PAIN                  [□R  or  □L]   □WRIST  PAIN            [□R  or  □L]   □ELBOW  PAIN          [□R  or  □L]   □HAND  PAIN              [□R  or  □L]   □LOCKING  

□GIVING  WAY  

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NAME:  ______________________________       DATE:____________________________  

 

HISTORY  MEDICAL  (CHECK  ALL  THAT  APPLY):  

□ASTHMA     □ARTHRITIS   □ANEMIA     □ANXIETY     □BLOOD  CLOTTING  TENDENCY  

□CATARACTS     □COPD     □DEPRESSION     □DIABETES  I  /  II     □DRUG  DEPENDENCY    

□EPILEPSY       □EMPHYSEMA     □GOUT       □HEADACHE     □HEART  DISEASE  

□HIGH  BLOOD  PRESSURE   □KIDNEY  DISEASE     □LIVER  DISEASE     □PEPTIC  ULCER     □PSORIASIS      

□VISION  LOSS     □CANCER  TYPE____________   □HEPATITIS  TYPE_______   □OTHER____________________  

 

ALLERGIES  TO  MEDICATIONS  (CHECK  ALL  THAT  APPLY):  

□ASPIRIN       □CODEINE       □  IODINE       □NOVACAINE       □PENICILLIN      □TAPE  OR  ADHESIVES   □SULFA   □OTHER__________________   □NO  KNOWN  ALLERGIES  

ARE  YOU:  □RIGHT  HANDED          □LEFT  HANDED          □AMBIDREXTROUS  

SMOKING  HISTORY:   □NEVER     □  PREVIOUSLY,BUT  QUIT     □CURRENT  SMOKER:  PACKS  PER  DAY___________________  

ALCOHOL  USE:     □NONE     □RARE     □SOCIALLY   □OCCASIONALLY  □OTHER  ___________________   PLEASE  LIST  ANY  MEDICATIONS  YOU  ARE  CURRENTLY  TAKING  INCLUDING  DOSAGE::  ___________________  ,  

___________________  ,  ___________________  ,  ___________________  ,  ___________________  ,  ___________________  ,  ___________________   PAST  SURGERY  

□APPENDECTOMY     □ARTHROSCOPY     □BACK  SURGERY     □BREAST  SURGERY      

□CARPAL  TUNNEL     □GALLBLADDER     □HEART  BYPASS     □HEART  VALVE  REPLACEMENT  

□HERNIA  REPAIR     □HYSTERECTOMY     □JOINT  REPLACEMENT   □NECK  SURGERY      

□PACEMAKER     □PROSTATE  SURGERY   □TONSILECTOMY     □OTHER_____________  

 

HEIGHT  ____FT____IN     WEIGHT  _______LBS     SHOE  SIZE  _____________      

LIST  PARTICIPATING  SPORTING  ACTIVITIES:  ___________________________________________________________________    

FAMILY  HISTORY  

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

PATIENT CONSENT FORM

The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal

health care information is protected for privacy. The Privacy Rule was also created in order to provide a

standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health

information about the patient to carry out treatment, payment, or health care operations.

As our patient, we want you to know that we respect the privacy of your personal medical records and will

do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect

your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only

those we feel are in need of your health care information and information about treatment payment of health

care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have

indirect treatment relationships with you (such as laboratories that only interact with physicians and not

patients), and may have to disclose personal health information for purposes of treatment, payment, or health

care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in

writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your

Personal Health Information, (PHI).If you choose to give consent in this document, at some future time you

may request to refuse all or part of your PHI. You may not revoke actions that have already been taken

which relied on this or a previously signed consent.

If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer. You have

the right to review our privacy notice, to request restriction and revoke consent in writing after you have

reviewed our privacy notice.

Printed Name: __________________________________________________________________________

Signature: _____________________________________________________________________________

Date: ___________________________

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

 

 

Please  check  all  appropriate  boxes:  

 

          I,  __________________________________give  permission  to  Howard  J.  Gelb,  MD,  Clive  C.  Woods,  MD,  

                   (Patient’s  name)  

               or  his  staff  to  leave  any  test  results  or  exam  results:      

  □  Leave  message  on  answering  machine  or  fax  at  home     □  Leave  message  with  spouse  or  family  member  

  □  Leave  message  with  ____________________(name  of  person)  

  □  Leave  message  on  voice  mail  at  work    

  □  Leave  message  with  only  myself  by  phone  or  fax  

 

  I,  __________________________________give  permission  for  my  medical  records  to  be  faxed  or    

       (Patient’s  name)  

mailed  upon  request  to:    

  □  My  Primary  physician  

  □  Any  other  physician  or  facility  that  will  be  involved  with  my  care  

  □  Dr.  Howard  Gelb  

  □  My  insurance  carrier    

 

  I,  __________________________________give  permission  to  Dr.  Gelb  or  Dr.  Woods  to  discuss  my  medical    

       (Patient’s  name)      condition  with:         □  My  spouse     □  My  children     □  My  parents     □  Other____________________________    

  I  hereby  authorize  the  release  of  any  medical  records  necessary  for  Dr.  Gelb  or  Dr.  Woods  to  render  medical  

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

LIABILITY STATEMENT

According to the information given to Dr. Gelb/Dr. Woods, I am being treated as a patient who was involved

in an auto accident for which I am holding another party liable for my injury.

I agree to supply the proper billing information necessary to cover any charges that are incurred during my

treatment with Dr. Gelb/Dr. Woods. However, I have been informed that regardless of insurance payments or

settlements. I am fully responsible for any balance not paid or covered by insurance or other parties involved.

I understand that the auto carrier and/or insurance company that I am seeking payment from may not cover

the entire bill. The standard reimbursement from an auto insurance carrier is 80% with benefit limitations

under PIP. Re-imbursement rates from other carriers cannot be determined or guaranteed. Private health

insurance companies and Medicare WILL NOT pay for non-covered amounts, therefore Dr. Gelb/Dr. Woods

WILL NOT BILL THEM FOR co-ordination of benefits.

I fully agree to pay any remaining balances to Howard J. Gelb, MD, PA within 90 days. I realize that

Dr.Gelb/Dr.Woods, do not accept payment from my insurance company as payment in full and does not wait

for litigation settlements for the balance of my bill.

I,__________________________________________________, agree to the terms explained above. In

addition, I understand that my account may be placed with a collection agency for any unpaid balances over

90 days. I will be responsible for any additional costs/fees for this process.

____________________________________________________ ___________________________

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HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine

Howard J. Gelb, MD, PA | 9980 Central Park Blvd N., Suite 222 | Boca Raton, FL 33428 | P: 561.558.8898 | F: 561.558.8868 | www.gelbmd.com

CLIVE C. WOODS, MD Orthopaedic Surgeon

Fellowship Trained in Foot and Ankle Surgery

 

 

INTENT TO TREAT LETTER

Auto  Insurance  Company:________________________________________________________  

 

Policy Number: _______________________________________________________________

Claim Number: _______________________________________________________________

This letter is to inform you that _____________________________________ is starting treatment at the offices of Howard J. Gelb, M.D./Clive C. Woods, M.D., located at 9980 Central Park Blvd North, Suite 222, Boca Raton, FL 33428. The patient is being seen for the injury which occurred on ___/___/_____. If you have any questions regarding this treatment, please notify the billing department at: 561-558-8898

In accordance with Florida Statute Section 627.736 (5) (b), the above medical provider has 75 days to submit medical statements. The patient has executed an Assignment of Benefits and Authorization to Release Medical Records on behalf of Howard J. Gelb, M.D. Accordingly, please provide an updated PIP payout ledger to this office every thirty (30) days.

Thank you for your anticipated cooperation.

Sincerely,

Howard J. Gelb, M.D. Clive C. Woods, M.D.  

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ASSIGNMENT OF INSURANCE BENEFITS,

POWER OF

ATTORNEY AND RELEASE INFORMATION

INSURER PLEASE READ THE FOLLOWING, IN ITS ENTIRETY, UPON RECEIPT:

I, the undersigned patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my No-Fault policy of automobile insurance, also known as Personal Injury Protection (P.I.P.), and Medical Payments policy of insurance to the above health care provider, Howard J. Gelb, M.D., P.A. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered and that this document will allow the provider to file against and Insurance company for payment of the insurance benefits. This assignment of benefits includes over due interest payments and any potential claim for common law or statutory bad faith. If the insurer disputes the validity of this assignment of benefits then the Insurer is instructed to notify the provider in writing within five (5) days of receipt of this document. Failure to inform the provider shall result in waiver by the insurer to consent the validity of the document. The undersigned directs the insurer to pay the health care provider directly without including the patient's name on the check.

The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim the contain or are accompanied by language releasing the insurer or its insured/patient from liability unless there has been prior written settlement agreed to by the health provider and the insurer as to the amount payable under the insurance policy or contract. The provider hereby objects to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted.

In the event the subject medical benefits are disputed by the insurer for any reason the undersigned hereby instructs the insurer to set aside any amount disputed (i.e., to escrow the money) and not pay the disputed amount to anyone, including myself, or any entity until the dispute is resolved. The insurer is instructed to immediately explain in writing to the above provider of any dispute. If the insurer schedules a defense examination or examination under oath (herein after 'EUO'0 the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider's attorney is authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer of the patient for any purpose.

This assignment applies to both past and future medical expenses and is valid even if undated. A photocopy of this assignment is to be considered as valid as the original.

I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts, and for any other services unrelated to the automobile accident.

Power of attorney: The above health care provider is hereby given the power of attorney by the undersigned to sign my name on any checks for payment for services rendered by the above provider.

Release of information: I hereby authorize this provider to: furnish the insurer, an insurer's intermediary and the patient's attorney via mail, fax or email, with any and all information that may be contained in the medical records; to obtain insurance coverage information in writing (declaration sheet) ad telephonically from the insurer: to request all EOBs and non-redacted PIP payout sheets from the insurer; and to obtain copies of all medical records, including but not limited to, documents, reports, scans, notes, opinions, X-rays, and MRIs, from any other medical provider or any insurer. The insurer is directed to deep the patient's medical records private and confidential. The insurer is NOT authorized to provide these records to anyone, including but not limited to, third party vendors without the patient's and the provider's prior express written permission.

I certify that I have not been solicited or promised anything in exchange for receiving health care or that I have received any promises or guarantees from anyone as the results that may be obtained by any treatment.

Caution! Please read before signing. If you do not completely understand this document please ask us to explain it to you. If you sign below we will assume you understand and agree to the terms!

I hereby accept the above Assignment of Benefits

PATIENT'S NAME______________________ (PLEASE PRINT)

PATIENT'S SIGNATURE________________________ DATE_________ (IF PATIENT IS A MINOR, SIGNATURE OF PARENT/GUARDIAN)

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FFICE OF

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NSURANCE

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EGULATION

Bureau of Property & Casualty Forms and Rates

OIR-B1-1571 Pub. 1/2004

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment set forth below were actually rendered. This means that those services have already

been provided.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider of the services described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid

by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500. Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

Name (PRINT or TYPE) Signature Date

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to

make a claim for Personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that

person to sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevant information

has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been

upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

Howard J. Gelb, MD or Clive C. Woods, MD

Name (PRINT or TYPE) Signature Date

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1)(b), Florida Statutes.

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