Insurance Assignment of Benefits

INSURANCE ASSIGNMENT OF BENEFITS

This Insurance Assignment of Benefits (the Agreement) is made and entered into on by and between Assignor Name: (Assignor) and Assignee Name: .

RECITALS

WHEREAS, Assignor is a patient or insured entitled to benefits, proceeds and payments under an insurance policy and/or contract described below; and

WHEREAS, Assignee provides medical, clinical or related services for which Assignor has sought or will seek insurance reimbursement; and

WHEREAS, Assignor desires to assign to Assignee any and all insurance benefits and rights to payment for services rendered by Assignee relating to the matters described below.

INSURER AND POLICY INFORMATION

ASSIGNMENT OF BENEFITS

For good and valuable consideration and to induce Assignee to furnish services, Assignor irrevocably assigns and transfers to Assignee all rights, title and interest in and to any and all insurance benefits, proceeds, payments and causes of action (collectively, Benefits) payable to Assignor for services rendered by Assignee for the treatment, care or services described herein, including past, present and future Benefits related to the matters set forth above. Assignor authorizes and directs the insurer named above to make payment directly to Assignee and to release information to Assignee necessary to adjudicate claims and benefits.

Assignor further authorizes Assignee to pursue, collect and enforce any rights of subrogation, reimbursement, or direct payment from the insurer to the extent of amounts assigned. If insurer pays Assignor contrary to this Assignment, Assignor agrees to hold such funds in trust for Assignee and to remit such funds promptly.

SCOPE OF SERVICES

PAYMENT TERMS

Total Charges to which Benefits are assigned: $

Late payment interest: If insurer or responsible party fails to pay amounts due to Assignee within thirty (30) days of final adjudication, a late fee of will accrue on outstanding balances, together with reasonable costs of collection, including attorneys' fees.

Assignor remains responsible for any copayments, coinsurance, deductibles or non-covered services unless otherwise indicated in a separate written agreement. Amounts collected by Assignee from insurer in excess of patient responsibility must be credited against Assignor's balance and, if appropriate, refunded to Assignor.

TERM AND TERMINATION

This Assignment is effective as of and shall continue until unless earlier revoked in writing. Either party may terminate this Assignment for material breach upon written notice delivered at least days prior to termination. Termination shall not affect Assignee's rights to collect Benefits for services rendered prior to termination.

CONFIDENTIALITY AND AUTHORIZATION

Assignor authorizes the release of medical and billing information necessary to process claims and to secure payment, and acknowledges that relevant protected health information may be disclosed to Assignee for these purposes. Assignee agrees to maintain confidentiality of patient information in accordance with applicable law and professional standards, except as required for claim adjudication, collection of Benefits, or as compelled by law.

I authorize direct payment of insurance benefits to Assignee.

I authorize release of medical and billing records to Assignee and insurer as necessary to process claims.

REIMBURSEMENT, SUBROGATION AND INDEMNITY

If Assignor receives any payments from insurer for services assigned to Assignee, Assignor agrees to hold such payments in trust for Assignee and to remit them to Assignee within five (5) business days. Assignor shall notify Assignee immediately upon receipt of any such payment. Assignor shall indemnify and hold Assignee harmless from any costs, losses or liability arising from Assignor's failure to remit assigned Benefits.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to its choice-of-law principles.

ENTIRE AGREEMENT

This Agreement constitutes the entire understanding between the parties with respect to the subject matter and supersedes all prior negotiations, understandings and agreements, whether written or oral. Any modification must be in writing and signed by both parties.

CERTIFICATION

By signing below, Assignor certifies under penalty of perjury that the information provided in this Assignment is true and correct to the best of Assignor's knowledge, that Assignor is authorized to assign the Benefits identified herein, and that Assignor understands and agrees to the terms of this Assignment.

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