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Form For Collecting "Med Pay" From Auto Insurance Carrier For Chiropractic Services
May 30, 2005

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To: (Insurance Agent)    
 Street Address  
 City, State Zip                                                                              Cc: Twin Palms Chiropractic Office
                                                                                                        333 Oren Avenue
                                                                                                        So. Grover’s Corners, WI 12345
From: (Patient Name)  
(Patient Home Address)                                                                   Cc: (Name of Attorney)
City, State Zip                                                                                     Attorney-at-Law
                                                                                                         Street Address
                                                                                                         City, State  Zip

Re: Auto Policy (Policy Number)  
DOI: (Date of Injury)                                                                       Claim (Claim Number)

Attached Claims for Medical Services rendered by Twin Palms Chiropractic Office

To (Name of Insurance Agent) and (Name of Insurance Company),

I hereby direct and authorize you, as my Wisconsin automobile insurance carrier, to open a claim against the “medical payment” portion of my auto policy as I am entitled and to pay the reasonable medical claims incurred as a result of the accident of  (date of accident or injury).

As per my policy and Wisconsin Statute, I direct you to pay medical payments for me as the policy owner, passengers of the vehicle I was driving and members of my immediate household This extends to those involved in the accident of (date of accident) including myself and : ________________________________________________

I hereby instruct and direct my insurance company to pay by check made out and mailed to:

Twin Palms Chiropractic Office
333 Oren Avenue
So. Grover’s Corners, WI 12345

for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGN-MENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to Twin Palms Chiropractic Office or John Smith, DC, and I have agreed to pay, in a current manner, any balance for professional service charges over and above this insurance payment. In consideration forTwin Palms Chiropractic Office billing for services and not collecting from me at time of service, I understand that this authorization and direction is irrevocable for the accident of (date of accident). A photocopy of this Assignment shall be considered as effective and valid as the original.

I am aware that there may be other liable parties or insurers involved with this accident. Under Wisconsin Statute Ins 6.11, Section (3) Unfair Claims Settlement Practices, Subsection (a) 9, I am using the available medical payments portion of my auto insurance policy to pay for medically necessary care rendered by this clinic. 

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

_________________________________________________  ____________________________________
Patient’s Signature       Date

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Petty, Michel & Associates
Practice Growth & Development Since 1988
Voice: (414) 332-4511 Fax: (414) 332-0909
Post: P.O. Box 170882 Whitefish Bay, WI   53217

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