ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND/OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE.
I hereby assign convey directly the above-named healthcare provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named healthcare provider, regardless of its managed care network participations status. I understand that I an financially responsible for ALL charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named healthcare provider to release all medial information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer and/or attorney to release to the above-named healthcare provider all documents, summary of benefit description, insurance policy and/or settlement information upon request from the above-named healthcare provider or its attorneys in order to claim such medical benefits.
In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or covey to the above-named healthcare provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies and/or medications I receive for the above-named healthcare provider (including any right to purpose those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach of fiduciary duty claims and other legal and/or administrative claims.
I intend by this assignment and designation of authorized representative to convey to the above-named healthcare provider all my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies and/or medications provided by the above-named healthcare provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above-named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me, (2) submit evidence, (3) make statements about facts or laws, (4) make any request including providing or receiving notice of appeal proceedings, (5) participating in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, healthcare benefit plan, or plan administrator. The above-named provider as my assignee and my designated authorized representative may bring suit against any such healthcare benefit plan, employee plan, plan administrator or insurance company in my name with derivative standing at providers expense.
Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (healthcare reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of the assignment is to be considered valid, the same as if it was original.
I have read and fully understand this agreement:
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