Dear Patient:
Recently, it has come to our attention that car insurance contracts will not reimburse the doctor directly for medical care received for injuries due to an automobile accident. Therefore, we are forced to amend our policy in relationship to accepting on “Med Pay” claims in
automobile accident cases.

If you are undergoing treatment in the office for personal injury sustained because of an auto accident, your automobile insurance carrier will pay you 100% of all reasonable charges directly through your “Med Pay” portion or your contract. Therefore, our policy regarding assignment on personal injury cases has been changed as follows: 

1. We do not accept as assignment the “Med Pay” portion of your automobile insurance contract, or third party legal claim unless you have an attorney involved and the attorney together with you are willing to sign a lien assignment insuring payment of our claim.
2. If you do not have an attorney that is involved in your case or is not willing to sign a lien assignment then your case will be handled in the following manner:

a) If you have personal health insurance that we verify that will pay us directly, we will submit claims as we normally would for any insurance claim. –or

b) You will be a cash patient. In this case, we will accept payment by credit card, check or financial arrangement can be considered on an individual basis. All claims will be billed to your auto insurance carrier on a weekly basis.

c) You may prepay portions of your treatment and received a cash savings discount.

Please note that by receiving this letter, it has been determined that you do not have an attorney involved in your case and / or we do not have a lien assignment on file. We would appreciate your cooperation by contacting Leslie Charles in our insurance department and make the necessary arrangements relative to your case.

Very truly yours,

R. Thomas Roselle, D.C., P.a.c.

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