ACCMED HEALTHCARE SYSTEMS, LLC

FLORIDA SPINE CARE

Dr. Bao T. Pham, DO

4205 Belfort Rd., Joe Adams Bldg., Ste. 3055, Jacksonville, FL 32216

Office 904-264-2677 Fax 904-264-2443

www.floridaspinecarejax.com

Date: ______

Dear Sir or Madam:

Our medical office is treating ______in connection with injuries sustained in an accident on ______/______/______. Our patient is aware that there is now, or may in the future be, an unpaid balance for these services related to this accident. It is our understanding that the patient has:

·  Auto Ins. with ______Policy/claim number is ______

·  Health Ins. with ______Policy/claim number is ______

·  Health Ins. with ______Policy/claim number is ______

·  Attorney Representation with ______

(Attorney’s Office Name) (Attorney Name)

·  A Letter of Protection with ______

(Attorney’s Office Name) (Attorney Name)

We feel certain that you will protect our rights to recover funds for these services from any settlement of this claim for which our office is providing medical care and treatment to this patient, to the extent there is sufficient insurance coverage and to the extent an equitable distribution can be accomplished. Please contact us when you would like an update regarding

the current balance on this patient account.

Please indicate below where our billing department should submit all claims pertaining to this injury.

_____Submit all claims to these carriers ONLY: ______

_____Submit all claims to these carriers ONLY: ______and

in addition, this patient will be protected under a Letter of Protection with the above attorney’s office.

_____DO NOT submit any claims to the above insurance companies, this patient’s balance will

be protected under a Letter of Protection ONLY.

Our patient appreciates your assistance and cooperation in this matter. If you have any further questions, please contact us at the above number.

______

Patient Name (PRINT) Patient Signature Date

______

Physician Name (PRINT) Physician Signature Date

______

Attorney Name (PRINT) Attorney Signature Date