Healthcare Personal Injury Protection Form

HEALTHCARE PERSONAL INJURY PROTECTION FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male   Female   Other

Insurance and Personal Injury Protection (PIP) Information

Insurance Provider:

Policy Number:    Group Number:

I hereby assert claim to Personal Injury Protection benefits for medical treatment arising from the incident described below. I understand that by signing, I authorize my insurer to pay medical benefits directly to the treating provider where assignment is accepted.

I assign Personal Injury Protection benefits to the treating provider and authorize direct payment of benefits to the provider to the extent permitted by my policy.

Incident Details

Date of Incident:    Time of Incident:

Medical History & Current Condition

Authorization, Release, and Certification

Authorization to Release Medical Information: I authorize any treating healthcare provider, hospital, clinic, insurer, and my attorney to release medical records, billing records, and any information related to treatment and payment for injuries sustained in the incident to my insurer, the assigned treating provider, and their authorized representatives for the purpose of claim adjudication and payment of Personal Injury Protection benefits.

HIPAA Acknowledgment: I acknowledge that I have been provided with the applicable privacy practices and that I consent to the disclosure of protected health information to the extent necessary to process PIP claims and coordinate care and payment. I understand that such disclosures may include mental health, substance use, and communicable disease information when relevant to treatment and billing.

Assignment of Benefits: To facilitate payment, I assign to the treating provider all rights and benefits payable under my Personal Injury Protection coverage for healthcare services rendered for this injury. If insurance proceeds are paid to me, I agree to immediately endorse and deliver such proceeds to the provider up to the amount of charges for services rendered.

Financial Responsibility: I understand that I am financially responsible for charges not paid by my insurer, including co-payments, deductibles, and charges determined not payable under the terms of my PIP policy. This form does not guarantee coverage or payment by my insurer.

Acknowledgment and Consent

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I authorize treatment of my injuries and consent to the release and use of my protected health information as described above. I understand I may revoke this authorization in writing, except to the extent actions have already been taken in reliance upon it.

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