Assignment of Benefits & Notice of Lien

In consideration of the willingness of IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC to treat me on credit without demand for payment at the time of services are rendered, I hereby agree and stipulate as follows:

I irrevocable assign IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC any proceeds or compensation that I am or may become entitled to receive as a result of injuries that occurred to the extent of Chiropractic services rendered.  I make this agreement without prejudice to any rights I may have to prosecute legal claims against any party who may be liable for my injuries, but I hereby authorize and instruct you to pay directly

IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC from any disability benefits, medical payments benefits, liability benefits, health and accident benefits, workers compensation benefits, judgments, settlements, or proceeds of any kind that would otherwise be payable to me, such sum as are due or may become due to IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC for his services rendered.

I appoint IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC as my attorney in fact to affix my name as an endorsement upon the reverse of any check or draft upon which I am named payee and to deposit said check or draft apply the proceeds to any unpaid balance I may have with IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC.

I authorize IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC to release to any insurer with applicable coverage or to my attorney or successor attorney any information regarding my injuries, prior medical history, or treatment as may be necessary to facilitate collection of proceeds under this assignment.

I acknowledge that I remain personally liable for the total amount due to IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC for services rendered, including any balance remaining after the application of insurance payments and settlement or judgment proceeds. If my case isn’t settled with-in a 6 month time period, I agree to begin making monthly payments at a rate of 100.00 per month until my case is settled or until my balance is paid off.

If IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC is required to take legal action against me to recover any unpaid balance on my account, I agree to reimburse IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC for its cost of recovery including reasonable attorney’s fees.

 Pursuant to N.C.G.S. 44-49 and 44-50, IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC hereby asserts and gives notice of a lien upon any sums recovered in damages for personal injury in any civil action and also upon funds paid to the above named patient in compensation for or settlement of injuries sustained whether in litigation or otherwise.  IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC hereby requests that if its claim(s) is not paid in full from foregoing proceeds, a full disclosure and accounting proceeds be provided in conformity with N.C.G.S.44-50.  IN HOME CHIROPRACTIC & PERSONAL TRAINING, PLLC agrees to be bound by any confidentiality agreements regarding the contents of the accounting.