Bluffton Medical Group, Hensley Legal Group
- Expense - Miscellaneous PI Fees $ 100.00 $ 2,389.14
- Amount Reduction Net Amount
- Alexander Shunnarah Law Firm $ - $ -
- Clear Choice Chiropractic $ 1,408.00 $ - $ 1,408.00
- Rawlings Financial Services, LLC $ 1,541.81 $ 560.67 $ 981.14 -$
- Amount
- Corrective Chiropractic
- Bluffton Medical Group
- Meridian Health Group
- Medical Account Balances Client to Resolve:
- DISBURSEMENT STATEMENT AND RELEASE:
- Once I sign and return this disbursement, I understand that I will receive a check in the amount of: 3,958.19$
- I understand that this check represents all monies due me for claims related to injuries I sustained in this incident
- I also understand that any further outstanding medical bills and liens, including health insurance, Medicare and/or Medicaid liens are my sole responsibility
- I understand that the outstanding medical account balances listed on this disbursement (below) are to Hensley Legal Group’s best knowledge and disclosed specifically by the providers
- Hensley Legal Group, PC is not responsible for any miscommunication regarding these balances
- If a balance given by the provider is incorrect, any remaining monies owed are my responsibility
- (Client Initial)
- Total to Client
- Provider
- Expenses
- Item Type
- Liens
- Lien Holder
- Bluffton Regional Medical Center - 13603695, Description (if any)
- Meridian Health Services - 0397738161
- Lutheran Health Physicians - 13769326
- Bluffton Regional Medical Center / 15661988 -, : (317) 472-3333
- Fax: (317) 472-3340
- Alexander Shunnarah Trial Attorneys
- Total to Client:
- CLOSING STATEMENT
- Armando C
- Sanchez958.19$
- Bluffton Regional Medical Center
- Clear Choice Chiropractic
- Client Signature
- Printed Name
- Date
- PLEASE SELECT METHOD OF PAYMENT
- The payment method cannot be changed once payment is initiated: Check will be picked up at the office Check will be mailed (INCLUDE ADDRESS BELOW)
- HLG has no control over USPS delays; if your check has not been received within 14 days of mailing, let us know Funds will be direct deposit by ACH
- See attached form to provide bank information; ACH payments may take 1-3 business days to post after the ACH payment is initiated
- Type your preferred method of payment below: (Pick-Up Check, Mail Check - INCLUDE ADDRESS BELOW, or Direct Deposit):
- E- Payments _________________________________________________________________________________________________________________
- Armando C
- Sanchez
- I hereby acknowledge that I am completely satisfied with the representation provided by Hensley Legal Group, PC, and hereby release them from any liability and further responsibility on behalf of myself in pursuing these claims
- I have also been advised that a copy of my file will be available for a period of two years from the date this disbursement is executed.
