Healthcare Assignment Agreement

HEALTHCARE ASSIGNMENT AGREEMENT

Parties and Effective Date

Patient Name:    Provider/Assignee Name:

Provider Address:

Effective Date:

Assignment of Benefits

For valuable consideration received, Patient hereby irrevocably assigns to Provider all rights and benefits to payment under any insurance policy, health plan, or third-party payer for healthcare services furnished by Provider relating to the condition, treatment, or services described below. Patient directs payment of benefits to Provider and authorizes Provider to submit claims, endorse and negotiate checks or other instruments, and pursue appeals on Patient's behalf.

Scope of Assignment:
Assign all current and future benefits and payments related to care provided by Provider
Assign benefits only for specific services described here:

Authorization to Release Protected Health Information

Patient authorizes any insurer, employer, health plan, healthcare provider, or other entity holding medical information to release to Provider and its agents any records or information necessary to adjudicate claims, coordinate benefits, or secure payment for services provided. This authorization includes disclosure of medical, billing, and claims information and is effective for the period necessary to process assigned claims.

Patient Financial Responsibility

Patient remains personally responsible for all charges not paid by the insurer or third-party payer, including co-payments, coinsurance, deductibles, non-covered services, and any portion denied as not medically necessary. Provider may bill Patient for unpaid balances and may assess interest, collection costs, and reasonable attorney fees if the account is placed for collection.

Period of Assignment and Revocation

This Assignment shall remain in effect until all claims and appeals related to the assigned services are fully resolved, unless earlier revoked in writing by Patient. Revocation will not affect payments made or actions taken in reliance on this Assignment prior to Provider's receipt of written revocation.

Medicare/Medicaid Certification (if applicable)

If Patient is enrolled in a government program that requires specific language for assignments, Patient certifies that the services described were necessary and relevant and authorizes Provider to submit claims and to sign on Patient's behalf any forms required by those programs to pay Provider directly to the extent permitted by law.

Representations and Remedies

Patient represents that Patient is the insured or authorized representative of the insured, and has full authority to assign benefits. Provider may seek recovery directly from Patient for any amounts received from third parties that are subsequently determined not to be payable to Provider. Provider may offset overpayments against future services or seek restitution as permitted by law.

Governing Law and Venue

This Agreement shall be governed by the laws applicable to contracts for the provision of healthcare services. Any dispute arising under this Agreement shall be brought in the appropriate forum with jurisdiction over the Provider's principal place of business.

HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands that information necessary to process claims and secure payments may be used and disclosed as described therein. Patient authorizes Provider to communicate claim and payment information to Patient and, if applicable, to Patient's authorized representative.

Patient Information

Insurance Information

Medical History (Relevant)

Additional Terms

Patient agrees to cooperate with Provider and insurer in the processing of claims, including timely submission of requested documentation and signatures. Patient authorizes Provider to forward any payments received on Patient's behalf to reduce outstanding balances. Provider shall apply recoveries in accordance with applicable law and the parties' reasonable expectations.

Acknowledgment and Certification

By signing below, Patient certifies under penalty of perjury that the information provided is true and correct, that Patient has read and understands this Assignment, and that Patient authorizes Provider to act as Patient's agent with respect to claims for the services described herein. Patient acknowledges receipt of a copy of this Agreement upon request.

Authorization Expiration

Unless otherwise specified, this authorization will expire upon final resolution of all claims and appeals related to services rendered on or before:

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