Common Contracts
1 similar Verification Agreement contracts
PERSONAL INJURY PROTECTION (PIP) VERIFICATION AGREEMENTVerification Agreement • July 29th, 2010
Due to HIPPA privacy regulations, Naturally Chiropractic cannot contact your auto insurance company for verification of the dollar amount of Personal Injury Protection Medical Benefits available for you on your auto accident claim. You must contact your auto insurance carrier directly for this information. To protect you from accruing a balance exceeding your PIP benefits for services rendered at Naturally Chiropractic, we request that you contact your auto insurance company (after 24 chiropractic adjustments, or 60 days of chiropractic care -whichever comes first) to verify the level of PIP benefits on your policy, and the remaining amount of PIP benefits available. By signing this form, you agree to contact your insurance company for the information described above, and to keep Naturally Chiropractic informed of any communications with your auto insurance company regarding your care, PIP benefits, independent medical examinations, and reports. This enables Naturally Chiropractic to h
