Injury Intake Integrative Medicine & Rehab

Last N ame: _ Middle Initial:___ First N ame:

Pho n e #:

Address: ______________________________________________

Work Phone #:____________________

City: _____________________________________

State

Age:

Primary Car e Physician Name:

Zip:________ E-mail Address: __________________________________________________

SS#: ________________________ D O B: ____/____ / ____ Male / Female

Physician Phone Number: _

ACCIDENT INFORMAT ION: Date of Accident: _ Where (Street / Intersection):_________________________

Were any tickets issued and to whom? ________________________________________________________________________

Were you the: O Driver O Front Seat Passenger (Right ) O Back Seat LEFT Passenger O Back Seat RIGHT Passenger

Did the impact to your vehicle come from the: O Front O Rear O Left Side O Right Side

Did the air bag deploy? O Yes O No Did you hit anything inside the vehicle? O Yes O No If yes, describe: _____________________

Did you experience immediate pain? O Yes O No Did the ambulance/ paramedics arrive at th e scene? O Ye s O No

Were you taken to the hospital? O Yes O No Did you drive to the hospital? O Yes O No Which hospital?

Were x-rays taken? O Yes O No MRI? O Yes O No CT? O Yes O No Did the they prescribe medication? O Yes O No

Are you currently taking medication? O Yes O No If yes, please name all:______________________________________ _ _ _ __ _ _ _

Please describe the accident in your own words: ____________________________________________________________________

_

FIRST (MAJOR) COMP LAINT: _________________________________________________________________

Date when symptoms first appeared: _____________________ Have you had this condition before?

Did it begin Gradual? O Yes O No Sudden? O Yes O No How long has it been going on? _______________

What makes symptoms increase? _______________________________ What relieves symptoms?_________________________

Type of pain: O Sharp O Dull O Aching O Burning O Throbbing How much of your day is pain? O 10 % O 25% O 50% O 100%

Pain Intensity (circle): NONE O 1 2 3 4 5 6 7 8 9 10 SEVERE

Does pain radiate into your (circle): L R Shoulder / Arm / Hand L R Buttocks / Leg/ Foot Does not radiate SYMPTOMS: Please check if you have experienced any of the following since this accident.

O Tension Across Top of Shoulders O Numbness/ Tingling in Arms/ Hands O Numbness/Tingling in Legs/Feet O Dizziness O Pain in the legs/feet/ buttocks O Pain in th e hand/ arm/shouldersO Difficulty with balance

O Tired/ Fatigued O Difficulty Sleeping O Ringing in Ears O Brain Fog O Nausea O Vomiting O Other: ____________________

O Low Back Pain O Pain between Shoulder Blades O Neck Pain O Difficulty talking O Tension/ Headaches O Changes in VisionO Difficulty swallowing

PREVIOUS ACCIDENT HISTORY: Have you ever been involved in another motor vehicle accident? O Yes O No If yes, please describe and give dates:________________________________________________________________________

Cell Phone #:

Application For Patient Care

Occupation: Employer: ________________________________

ACCIDENTS

Average # Hours per week currently worked:

Type of Tasks Performed/Common Movements: ___________________________________

Marital Status: O Single O Married O Divorced O Widowed O Separated O Minor

_ Spouse's Name: # Of Children Children's Ages:

Emergency Contact Name: Relation: Phone#: _

Do you have auto insurance? O Yes O No Name of Carrier: ______________________________

Do you have health insurance? O Yes O No Name of Carrier: ______________________________

Do you you have secondary insurance? O Yes O No Name of Carrier: ________________________

PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)

Assignment and Release (insured patients) I certify that I (or my dependent ) have insurance coverage with ___________________ and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN PRACTICE, Integrative Medicine & Rehab INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature e on all in insurance claims, including electronic submissions.

SIGNATURE (X_) __________________________________ DATE __________________________ _ _ _ _ _ _ _ _ _ _

9101 W. College Pointe Dr. Suite 1 Fort Myers, FL 33919 Ph: 239-208-0088

Have you had an auto accident? {X if applies): O 0-6mo O 6 mo-1 yr O 1-3yrsO 3+yrsO Never

Had a recent fall/other accident? (X if applies): O 0-6mo O 6 mo-1yr O 1-3yrs O 3+yrs O Never

Have You Ever Received Chiropractic Care? O Yes O No Last Visit? ____________________

Have You Ever Received Physical Therapy? O Yes O No Last Visit? ___________________

PAT

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ACCIDENTS

ACCIDENTS

Patient Name _ Date _

PATIENT HEALTH HISTORY Please check to indicate if you are currently experiencing any of the following conditions and then circle problematic areas on body to right: O Neck Pain/Stiffness O Back Pain/Stiffness O Arm/Hand Pain O Leg/Knee Pain O Headaches O Night Pain O Depression O Cold Extremities O Nervousness O Sleeping Difficulties O Jaw Problems O Loss of Smell O FaintingO DizzinessO Stomach Problems O Asthma O Swollen Joints O Mood Changes O Foot Trouble

O Pins/Needles in Arms O Pins/Needles in Legs O Light Bothers Eyes O Recent Weigh Change O Loss of Memory O Nausea O Loss of Taste O Fatigue O Chest Pain O Tension O Fever O Cold Sweats O Constipation/Diarrhea O Allergies O Shortness of Breath O Blurred/Double Vision O Bowel/Bladder Changes O Trouble Concentrating O Loss of Balance

Please check if you have ever had any of the following: O Sexual Difficulty O Stroke O Suicide Attempt O Thyroid Problems O Pain O Tonsillitis O Tremors

O ADD/ADHDO Aids/HIVO Alcoholism O Allergy Shots O Anemia O Anorexia O AppendicitisO Arthritis

O Asthma/Wheezing O Bad Breath/Bad Taste

O Tuberculosis O Tumors/GrowthsO Typhoid Fever O Ulcers

O Heart Attack O Heart Problems O Hemorrhoids O Hepatitis O Hernia O Herniated Disc O HerpesO High Cholesterol O Hormone/Gland Problems O Insomnia O Kidney Problems O Liver DiseaseO Measles

O Vaginal Infections O Venereal Disease O Whooping Cough O Other:

O Bleeding Disorders O Blood Pressure: High or Low (circle) O Breast Lump O Broken Bones O Bronchitis O Bulimia

O Cancer O Cataracts O Chemical Dependency O Chicken Pox O Colon Trouble O Contacts/GlassesO Diabetes O Dry Skin O Ear Infections O Epilepsy O FracturesO Gall Bladder O Glaucoma O Goiter O Gonorrhea O Gout O Heartburn

O Menopausal Prob. O MigrainesO Miscarriage O Mononucleosis

O Mouth Sores or Bleeding Gums O Multiple Sclerosis O Mumps O Nosebleeds O Osteoporosis O Pacemaker O Parkinson's Disease O Pinched Nerve O Pneumonia O Polio O Prostate Problems O Prosthesis O Psychiatric Care O Rheumatoid Arthritis O Rheumatic Fever O Scarlet Fever

Are you currently under drug and/or medical care? O Yes D No If yes, explain

Please list any and all medications you are currently taking: _

Please list any surgeries and/or hospitalizations you have had (type & date): _

9101 W. College Pointe Dr. Suite 1 Fort Myers, FL 33919 Ph : 239-208-0088

Patient Name. _ Date

ALLERGIES: (Please place a check mark next to any known allergy that you have.)

_Milk _Eggs _Peanuts _Almonds _Cashews _Walnuts _Fish _ Shellfish _Soy _Wheat _Gluten _Penicillin _Sulfa Drugs _Tetracycline _Codeine _NSAIDS _Phenytoin _Carbamazepine _Mildew _Mold _ Dust _Fungus _Mites _Tree Pollen _Grass Pollen _Weed Pollen _Insects _Dog Dander _Cat Dander _Latex _Other Animal Dander _OTHER: (please/ill in)

Please list any supplements you are currently taking (vitamins/herbs/minerals): _

Is there a family history of any of the following conditions? (Indicate family member including parents, grandparents & siblings)

O Heart Disease

9101 W. College Pointe Dr. Suite 1 Fort Myers, FL 33919 Ph : 239-208-0088

O Cancer O Arthritis _ O Diabetes _

Exercise Level: O None O Occasional O HeavyO Moderate

Do your work activities mostly involve: O Sitting O Standing O Light Labor O Heavy Labor

Do you sleep on your: O Back O Side O Stomach

What is your daily/weekly intake of the following:

Do you use a cervical pillow? O Yes O No

Caffeine cups/day Alcohol drinks/week Cigarettes packs/day

I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health. I will give complete and accurate information during my exam.

SIGNATURE (X) _ DATE

Date Patient's Signature

Date of last menstrual period: _

X-ray Questionnaire: For women onlyOur consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant at this time.

Name: _

O There is a possibility that I a may be pregnant at this time.

O Yes, I am definitely pregnant

O No, I am definitely not pregnant at this time

O I request that x-ray films not be taken because: _

Integrative Medicine & Rehab 9101 W. College Pointe Dr. Suite 1 Fort Myers, 33919 Ph: (239)208-0088 Fax: (239) 288-0804 www.imedandrehab.com

RECORDS RELEASE AUTHORIZATION

Date:_____

To Doctor or Hospital:

Name: _________________________

Address: __________________________

Phone: ______________________

Fax: ________________________

I hereby authorize and request release to:

The complete history records in your possession, concerning my illness and/or treatment during the period:

Patient: _________________________________ DOB: ______________________

SSN #: __________________________________

Patient Signature: __________________________ Date: ________________

THIS FAX IS INTENDED ONLY FOR THE USE OF THE PERSON OR OFFICE TO WHOM IT IS ADDRESSED, AND CONTAINS PRIVILEGED OR CONFIDENTIAL INFORMATION PROTECTED BY LAW. ALL RECIPIENTS ARE HEREBY NOTIFIED THAT INADVERTENT OR UNAUTHORIZED RECEIPT DOES NOT WAIVE SUCH PRIVILEGE, AND THAT UNAUTHORIZED DISSEMINATION, DISTRIBUTION, OR COPYING OF THIS COMMUNICATION IS PROHIBITED. IF YOU HAVE RECEIVED THIS FAX IN ERROR, PLEASE DESTROY THE ATTACHED DOCUMENT(S) AND NOTIFY THE SENDER OF THE ERROR BY CALLING 239-208-0088. IF YOU DO NOT RECEIVE ALL OF THE PAGES, OR IF YOU HAVE ANY PROBLEMS WITH THIS TRANSMISSION, PLEASE CALL 239-208-0088

Integrative Medicine & Rehab9101 W. College Pointe Dr.Suite 1Fort Myers, FL 33919Phone: 239-208-0088Fax: 239-288-0804

Priva cy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HO W YOU CAN GET ACCESS TO THIS INFORM ATION. PLEASE REVIEW IT CAREFULL Y. In the course of your care as a patient at Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) we may use or disclose personal and heal th related information about you in the following ways:

• Your personal health information, including your clinical records, may be disclosed to another healthcare provider or hospital if it isnecessary to refer you for further diagnosis, assessment or treatment.

• Your healthcare records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, aPPO, or your employer, if they are or may be responsib le for the payment of your services.

• Your name, address, phon e number, and healthcare records may be used to contact you regard ing appointment reminders,inform ation about alte rnative s t o your present care, or other health related information that may be of interest to you.

If you are not at home to receive an appointment reminder, a message may be left on your answering machine. Furthermore, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization n in the following circumstances:

• If we are providing health care to you based on the orders of another healthcare provider.• If we provide health care services to you in an emergency.• If we are required by law to provide car e to you and we are unable to obtain your consent after att empting to do so.• If th re are substantial barriers to communicating w it h you, but in our profession al judgment we believe that you intend for us to

provide care.• If we are ordered by the courts or another appropriate agency.

Any use or discloser of your protected health information, other than as outlined above, will only be made upon your writt en authorization.

We normally provide inform ation about your health to you in person at the time you receive physical medicine care from us. We may also mail information to you regarding your healthcare or about the stat us of your account. If you would like to receive this in formation at an address other than your home or if you would like the inform ation in a different form, please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend our health related information ion should be provided to us in writing.

We are required by state and federal law t o maintain the privacy of your patient file and the protected heal th information therein. We are also required to provide you with this n o tic e of our privacy pr act ices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the term s of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply to all of your information in our files.

Information that we use or disclose based on this privacy notice may be subject to re-discloser by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: Brooke Iwanski. If you would like further information about our privacy policies and practices please contact: Brooke Iwanski.

My signature acknowledges that I permit Dr. Brooke Iwanski, D.C., LLC (DBA Integrative Medicine & Rehab) to download and access the prior 13 (Thirteen) months of my medication history through my insurance company.

This notice is effective as of December 1, 2011. This notice, and any alterations or amendments made hereto will expire seven (7) years after the date upon which the record was created. My signature acknowledges t hat I have received a copy of this notice.

Name (Print) Signature Date

TERMS OF ACCEPTANCE AND CONSENT FOR CARE

We will attempt to identify and diagnose any ailments you may have that may be corrected through physical medicine, active/passive rehabilitation, and/or chiropractic care, and/or massage therapy. If any condition or disease appears to be present out of our scope of practice, we will refer you to an appropriate physician to diagnose and/or treat that condition.

The primary focus of care in this office is the detection and correction of Neuromusculoskeletal conditions as well as lifestyle modification for the correction or amelioration of physiological and physical ailments.

Through specific tailored treatment plans, we reduce and/or correct physical or physiological disturbances. It may be necessary to examine an individual each time a new injury occurs and often x- rays or other diagnostic procedures are necessary to maintain the utmost safety when dealing with your body. The risks of physical medicine, active/passive rehabilitation, chiropractic care, and/or massage therapy are minimal when dealing with a licensed professional; however, if you have concerns about these risks, please discuss them with the doctor prior to the examination. I also under st and that the fee paid for treatment x-rays is for analysis only. The file itself is the property of this office. Once films are taken, they cannot be released, but may be copied. There is a fee for copying of the x-rays.

Also, for your protection, portions of our office where patients do not disrobe are under video surveillance, specifically, but not limited t o, the front desk check-out st at i ons.

I have read and I accept the terms above and understand them fully. I hereby give consent to the DR. BROOKE IWANSKI D.C., LLC {DBA Integrative Medicine & Rehab} to evaluate me to determine my condition and treat me for such conditions. I also understand that I may at any time discontinue with the exam and/or x-rays or any treatment if I so choose.

I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered to me will be immediately due and payable. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect this amount.

I,____________________ have read and fully understand the above statements. (PRINT NAME)

(SIGNATURE) (DATE)

FOR MINORS:

I, __________________________being the parent or legal guardian of _ _ _______________________ _ _ _ _ , (Print Guardi an Name) (Print M ino r's Nam e)

Have r ead and fu lly understand the above t erms of acceptance and hereby grant permission for my child to receive treatment.

(SIGNATURE) (DATE)

9101 W. College Pointe Dr. Suite 1, Fort Myers, FL 33919 Phone: 239-208-0088

CONSULTATION REQUEST FORM From: To:

Name:___________________________ Florida Injury Medical Centers Address:_________________________ 432 N. Pine Meadow Dr. ________________________________ Debary, FL 32713 Phone:__________________________ Phone: 386-742-7312 Fax:____________________________ Fax: 386-742-7116

Referral r Medical Consult r Medical Co-management

PATIENT INFORMATION Name:______________________________________________________________________________________

Address:____________________________________________________________________________________

Phone:____________________________________ E-mail:____________________________________________

Date of Birth:_______________________________Date of Injury:_______________________________________

INSURANCE: _________________________________________________________________________

CLAIM NUMBER:____________________________________________________________________

ATTORNEY:_____________________________________Phone:______________________________

r See additional information attached.

Signature: _______________________________________________ Date ___________________

Integrative Medicine & Rehab

9101 W. College Pointe Dr.

Suite 1b

Fort Myers, FL 33919

P. 239-208-0088

F. 239-288-0804

Initiation of Treatment

---__________________________________________________________________ _

Patient Name:

Social: Security: _

Insurance Carrier: ·----"""----------------

DoL: ---------------------

Date First Seen: _____________

Patient DOB:. ______

From: BROOKE IWANSKI, DC

Dear Personal Injury Protection Insurer:

We are hereby submitting notice to you that we have initialized examination and/or treatment

for your insurance. The patient's first date of treatment occurred on ___.

Enclosed, please find a direction to pay, which the patient has directed you to send all payment

for services rendered to the undersigned. The patient has also granted us a lien on the

benefits.

In accordance with F.S. 627.736(5) (b), our office will be submitting bills in a timely manner.

Please retain this notice in your claim file.

Thank you,

BROOKE IWANSKI, DC

Insurance Policy#: ___________

Claim#: _____________

Integrative Medicine & Rehab (239)208-0088

9101 College Pointe Dr. Suite 1 Fort Myers,FL 33919

AUTHORIZATION.LIEN.ASSIGNMENT OF BENEFITS & CONSENT/GUARANTEE OF PAYMENT

RELEASE OF INFORMATION: I authorize Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine and Rehab) to release any infonnation pertinent to my case to any insurance company, attorney, adjuster to facilitate collection under this authorization and assignment I hereby release you of any consequences thereof. I authorize you to communicate with other doctors as it pertains to my diagnoses or treatment. l also authorize any holder of medical & chiropractic information about me to release the health care financing administrators or insurance adjustor agents any information needed to determine these benefits for related services.

ASSIGNMENT OF CAUSE OF ACTION: In the event my insurance company is obligated to make payments to me upon the charges by Integrative Medicine and Rehab. for their services and refuse to make such payment, upon demand by me or Assignee, I hereby assign and transfer to you any and all cause of action that exists in my favor against any said company and authorize you to prosecute said claim or cause of action as you see fit However, it is understood that until all reasonable efforts have been made to collect sums due from the insurance company (or companies) contractually obligated, you will refrain from attempts and efforts to collect the amount owed directly from me. I understand that I am responsible for the amounts that the insurance is not directly obligated due to PIP laws. D�CTION TO PA Y:TO: I authorize __________________and direct you, my insurance company and/or my Attorney, to Pay Directly to Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine and Rehab) any sums as may be due and owing them for medical service rendered me both by reason of this accident, or illness and/or by reason of any other bills that are due their office and to withhold such sums from any settlement, judgment or verdict on my behalf as may be necessary to adequately protect Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine and Rehab). I hereby further give a lien on my case to said company against any and allproceeds of any settlement,judgment, or verdict which may be paid to you, my attorney, or myself as a result of the injuries for which Ihave been treated or injuries in connection herewith. This is to act as an assignment of my rights and benefits to the extent of theAssignee's services provided. Further, I hereby instruct the insurance carrier to request that, in the event the subject medical services and/or benefits are disputed for any reason, the amount of benefits being claimed by Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) are to be held in escrow and not disbursed until the dispute is resolved. I agree that the above mentioned be given Special Power of Attorney to endorse/sign my name on any and all claim for payment of my bill. If my policy prohibits direct payment to the provider, then I hereby also instruct and direct you to make checks payable to me & Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) and mail the payment to me, in care of Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab)To

9101 W. College Pointe Dr. Suite 1b Ft. Myers, FL 33919

NOTIFICATION OF CHANGES: I will notify Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab)changes in my health status, home and work infonnation, or anything else relating to the infonnation on this intake sheet.

CONSENT FOR TR.EA TMENT & GUARANTEE OF PAYMENT: I hereby consent to the rendering of healthcare services for me or my child listed below. I voluntarily consent to examination and x-rays to aid in evaluating my/our case. I declare that I am not pregnant, nor is pregnancy suspected. I also voluntarily authorize the doctor to treat my condition as he deems appropriate. I have been advised that Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab). is willing to wait for payment for these services, provided that there continues to be a reasonable chance that payment will be made either by insurance proceeds or out of the settlement of a liability claim. I authorize my attorney to guarantee payment out of any settlement that is awarded in regard to my case and that I authorize this payment be made before any monies released to me. I understand that if it is determined either:

A. That there is no insurance company obligated to pay for the services, or if the insurance company involved refuses to acknowledge an assignment to the assignee or make other provisions for the protection of the interest of Dr. BrookeIwanski, D.C. LLC (DBA Integrative Medicine & Rehab) orB. If a liability claim exists, and my attorney refuses to agree to protect the interest of Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) or if

I have not engaged the services of an attorney: Then payment of services rendered by Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) or

will be made on a monthly bases and my bill paid in full as soon as my liability is settled or the passage of 4 months from my last treatment, whichever occurs first (Unless a separate written agreement is made with Integrative Physical Medicine of Winter Haven, LLC .. ). When no LOP exists and the account reaches 60 days overdue, it may be subject to 1.5% per month (18% per year) finance charge. If the default amount is referred to a collection agency and/or for legal action, I agree to pay for reasonable costs of collection.

My signature below verifies I have read and understand the above condition of acceptance as a patient and or guardian at Dr. Brooke Iwanski, D.C. LLC (DBA Integrative Medicine & Rehab) and I agree to these conditions.

_____________________________ _______________________________________ __________________________Print Patient Name Signature of Patient or Guardian Date

OFFICE OF INSURANCE REGULATION 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):

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.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.