If you are reading this document, you have been in an accident and have potentially sustained injuries. Since there are insurance companies, property damage, personal injuries and possibly attorneys involved, it is no longer a medical issue but a legal one. You will need to provide information that is vitally important in order for Bailey Chiropractic Centre to initiate treatment. If you are unable or unwilling to provide all of the following information, we cannot and will not be able to treat you.

INFORMATION NEEDED BEFORE INITIAL TREATMENT

• ACCIDENT REPORT / EXCHANGE SLIP

• PHOTO ID

INSURANCE INFORMATION

• INSURANCE CLAIM # OF AT FAULT PARTY

• NAME            ADDRESS                PHONE #        
  FOR INSURANCE COMPANY AND CLAIM REP

• MEDPAY CLAIM # WITH YOUR AUTO INSURANCE COMPANY
  

• NAME            ADDRESS                PHONE #        
  FOR INSURANCE COMPANY AND CLAIM REP

• MEDICAL INFORMATION PERTAINING TO THE ACCIDENT
  (i.e., doctor's offices, hospitals, including MRIs, CT Scans, X-Rays and office notes)

Attorney Information

• DO YOU HAVE AN ATTORNEY        Y     N
  IF SO, WHOM? ____________________________________________________________

• IF NO, DO YOU HAVE PLANS TO RETAIN AN ATTORNEY       Y  N
  IF SO WHOM? ____________________________________________________________

Note: You are not required to retain an attorney if you are injured in an accident. If you find you are having difficulties with insurance companies closing the case you can retain an attorney at any time. You must let us know if you are thinking about retaining one.

OFFICE POLICY CONCERNING PERSONAL INJURY CASES

Now that we have established that this is a legal matter, it is important for you to know the following:

• Most patients are unaware that they do NOT have to retain an attorney to settle a case. We have found that insurance companies will settle directly with the patient with little trouble. There are some guidelines to remember if you choose to settle your own case. Please Ask Questions!

• If at any time you choose to retain an attorney, you must let us know as soon as possible, preferably before you retain one. There are a number of attorneys that we will not work with due to the nature of their business practices. Please speak with us before hand. We will only work with attorneys that look after everyone's best interest not just their own. If you choose to go outside these requests I hold the right to end our Doctor / Patient relationship.
  

Bailey Chiropractic Centre will not be held responsible for a decision that a patient makes over the choice of a bad attorney. Ultimately You, the patient, are receiving treatments for your injuries and thus you will be held ultimately responsible for any remaining balance on your account. It is, therefore necessary, to follow these guidelines or we will release you from care.

Please keep in mind we will evaluate each individual case based upon the information provided.

Insurance Terms Related to Auto Accidents as it Relates To YOU:

• Liability: Always filed against the party at fault.
• Uninsured: Filed Only if at fault party is uninsured.
• Underinsured: Filed Only if the at fault party is underinsured.
• Medical Payments: Always filed if you have it.

We have enclosed a copy of the medical payment law as it pertains to North Carolina.

Medical Payments are usually in the form of 1K, 2K, 3K or 5K. This amount is to be used for MEDICAL PAYMENTS hence the name MED PAY!

You are able to use your med pay, not exceeding the cap amount you have purchased. It is regardless of fault and it is per person in the vehicle and per occurrence.

It is important to remember that if you have Medical Payments on your auto insurance you have already paid your premiums for the coverage and do so every month or quarter and thus it will not make those premiums increase, nor will it effect your deductible. It is already bought and paid for and it is to be used to pay your medical provider for services rendered in the treatment of your injuries sustained in a Motor Vehicle accident. Please read the enclosed state law.

If you have Med Pay on your auto policy, we will need you to set up a claim before any examination or treatment can begin. Please talk to Suzanne about the procedure.

If you are under the impression that these funds are to be used by you for whatever you wish you will need to see another provider. At Bailey Chiropractic Centre it will be used to get your medical bills paid in full.