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3500 Nostrand Ave, Brooklyn, NY 11229

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Statement Form

STATEMENT

In an attempt to enhance our services, our office is staffed with qualified physicians, chiropractors and exercise physiologists.

Our complete rehabilitation program incorporates physical medicine, manipulation, physical therapy and a full line of exercise equipment.

To simply provide you with the utmost quality services, our staff at HealthQuest will answer any questions regarding billing, collections, and insurance co-payments. As per this letter, I understand the medical, rehabilitation and/ or chiropractic care rendered by a physician, chiropractor or their assigned assistants as per rules and definitions of HealthQuest. We are a private corporation and we are staffed by, but not limited to Dr. Igor Stiler, Ravi Salickram, P.A., Mathew Valvo, P.A., Dr. Leslie Klein, Dr. Russell Greenseid, Dr. Nick Chiappetta, Dr. Christos Vasakiris, Dr. Ralph Mangels, Karl Hao Cuenco P.T.

The staff at our facility will be more than happy to answer any questions that you may have. We render the best care and welcome you to our facility.

It is very important that you NOTIFY THE FRONT DESK about the following information.

NO-FAULT:


  • WHEN YOU HEAR FROM YOUR INSURANCE CARRIER ABOUT THE DATE OF YOUR INDEPENDENT MEDICAL EXAMINATION (IME)
  • WHAT THE RESULT OF THAT INDEPENDENT MEDICAL EXAMINATION (IME) IS.
  • IF YOUR MEDICAL BENEFITS HAVE BEEN DENIED.
  • IF YOU HAVE CHANGED ATTORNEYS.

WORKERS COMPENSATION:


  • IF YOU ARE WORKING OR NOT WORKING.
  • IF YOUR WORK STATUS HAS CHANGED.
  • IF YOU ARE WORKING LIGHT DUTY OR FULL DUTY.
  • IF YOU HAVE A HEARING DATE COMING UP.
  • IF YOUR MEDICAL BENEFITS HAVE BEEN DENIED.

*****COMPLETION OF MEDICAL FORMS $10.00*****

I have read and understand the above information and I will notify the front desk as soon as I hear from my insurance carrier about any of the above information.

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