Healthcare Work Assignment

HEALTHCARE WORK ASSIGNMENT

Patient Information

Patient Name:   Date of Birth:

Phone:   Email:

Assignment Details

Assignor (Patient or Authorized Representative):

Assignee (Provider or Facility Name):

Effective Date:   Anticipated Completion Date:

Services to Be Performed

Insurance and Billing Assignment

Primary Insurance Provider:   Policy Number:

Group Number:   Subscriber Name:

Assignment of Benefits:

By signing below, the Assignor assigns to the Assignee all rights to payment from any third-party payor, including but not limited to insurance benefits, Medicare, Medicaid, or other available sources, for services provided under this Work Assignment. The Assignor authorizes direct payment to the Assignee and authorizes release of medical information necessary to secure payment.

Medical History and Clinical Information

Authorization and Consent

The Assignor hereby authorizes the Assignee to perform the services described in this Work Assignment and to take those actions reasonably necessary to provide such services. The Assignor acknowledges that the Assignee has explained the nature of the services, foreseeable risks, potential benefits, and alternatives where applicable.

Revocation: This authorization may be revoked by the Assignor in writing at any time, except to the extent that the Assignee has already taken action in reliance on this assignment. Revocation will not affect actions taken prior to receipt of written notice.

Authorization Expiration Date:

HIPAA Acknowledgment

By signing this form, Assignor acknowledges receipt of and understands the Assignee's privacy practices and authorizes disclosure of protected health information to third parties as necessary to carry out treatment, payment, and health care operations related to this Work Assignment.

Check applicable statements:

Consent to treatment by Assignee

Consent to release information for billing and payment purposes

Representations, Warranties, and Indemnity

The Assignor represents that the information provided on this form is true and accurate to the best of their knowledge. The Assignor warrants that they have the authority to assign the rights identified herein. The Assignor agrees to indemnify the Assignee against claims arising from false information provided by the Assignor or revocation in breach of obligations herein.

The Assignee agrees to perform assigned services in a professional manner consistent with applicable standards of care and to comply with applicable privacy and confidentiality obligations.

Term and Termination

This Work Assignment begins on the Effective Date and continues until the completion date unless earlier terminated by mutual written agreement, by Assignor upon written revocation (subject to reliance limitations), or by Assignee for cause with written notice. Termination does not affect rights to payment for services performed prior to termination.

Notices

All notices required or permitted under this Work Assignment shall be given in writing to the addresses set forth above for the Assignor and Assignee and are effective upon receipt.

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