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Cross River Pain Management Part 3


73-24 195 St.

Fresh Meadows, NY, 11366

Ph: 718-690-2572

Fax: 718-886-1868

To Attorney:


Date of Accident:


I do hereby authorize

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 recently involved.

I hereby authorize and direct you, my attorney, to pay directly to said doctor/medical facility such sums as may be due and owing said doctor/medical facility for medical services rendered to 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/medical history. I further give a lien on my case to said doctor/medical facility against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the 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 said doctor/medical facility for all medical bills submitted by doctor/medical facility for services rendered to me and that this agreement is made solely for said doctor/medical facility's additional protection and in consideration of said doctor/medical facility awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict from which I may eventually recover said fee.


In the case of automobile accidents, where no-fault regulations govern the medical reimbursement, this lien will be effective only to the extent of those applicable no-fault regulations.


The undersigned being attorney for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment or verdict, as may be necessary to adequately protect said doctor above-named.


Cross River Pain Management

Assignment of Benefits and LTD Power of Attorney

I hereby assign benefits and authorize payment directly to DG Pain Management and/or its staff (hereinafter collectively "You") of any insurance benefits made as a payment to me (or a minor for whom I am the guardian) for their services provided to me (or a minor for whom I am the guardian) for their services. I agree to immediately forward to this office any insurance payments which are made directly to me.

irrevocably assign to you, DG Pain Management, my medical provider, all of my right and benefits under my Insurance contract for payment for services rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically included filling arbitration /litigation In your name on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize you to act on my behalf. I consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to the "benefit denial appeals process" set forth in the NY Administrative code. I request that the insurance carrier consent to my assignment of benefits within 10 days of receipt otherwise it is deemed consented to.


As a medical provider I agree to attempt to reasonably comply with the PIP carrier's decision point review/pre­ certification plan and to hold the patient harmless if I fail to comply with same, in consideration for the carrier's consent to this assignment.


In the even the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid. I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case in my name or in your name as a medical provider rendering services to me and designate your collection agency as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me.


I authorize you and your attorney to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to release call such information to you about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my physical condition.

I understand that I am responsible for all fees charged, whether they are covered by insurance or not. Also, I am aware it is my personal responsibility to monitor insurance payments and maximums. If I receive any payment in trust for:

and I also agree to send such payment to:

within one week after receipt of same. I also agree to pay attorney's fees equal to 33 1/3% of the outstanding balance, plus court costs, in the event the account is turned over to an attorney for collection.

Cross River Pain Management

Acknowledgement of Patient Rights and Privacy Practices

By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by our practice listed at the beginning of this notice, and how I may obtain access to and control this information.

Cross River Pain Management

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information.


At this time, I am requesting the following:

I understand that you will provide this information within 15 business days from receipt of request, and you may charge a fee for preparing and furnishing this information.


The fee is waived because the records are to be used for supporting an application for disability or other benefits or assistance under Aid to Families with Dependent Children, Medicare, Supplemental Security Income, and Federal Old-Age and Survivors Insurance. I have attached a statement which confirms that such an application or appeal has been filed or is pending.

Cross River Pain Management

Controlled Substance Agreement Contract

I understand there are risks involved with chronic controlled substance (narcotics, pain killers, sleeping pills, nerve pills) administration including, but not limited to dependence, addiction, sleep and appetite changes; constipation and even bowel obstruction; and change in sexual desire and performance. I understand that the inappropriate use of medications such as mixing with another substance can cause death.

Please check the box on each item and sign below:

CRP - Controlled Substance

Thanks for submitting!

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