Legal AOB & AOP Agreement

LEGAL AOB & AOP AGREEMENT

This Assignment of Benefits and Authorization of Payment Agreement (Agreement) is entered into as of Effective Date: by and between Assignor Name: (Assignor) and Assignee Name: (Assignee). Collectively the parties are referred to herein as the Parties.

RECITALS

WHEREAS, Assignor is the policyholder or claimant under an insurance policy or benefit program identified by Insurer Name: and Policy/Plan No.: ; and

WHEREAS, Assignor has received or will receive services or supplies from Assignee that give rise to claims for benefits or payment (Claims) under such policy, plan or contract identified by Claim Number: ; and

WHEREAS, Assignor desires to assign to Assignee certain rights to payment under the policy or plan and to authorize direct payment of such benefits to Assignee, and Assignee desires to accept such assignment and authorization subject to the terms set forth herein.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the Parties agree as follows:

1. ASSIGNMENT OF BENEFITS

1.1 Assignment. Assignor hereby irrevocably assigns, transfers and conveys to Assignee all right, title, interest and entitlement to payment of benefits and proceeds payable by any insurer, plan administrator, third-party payor, or governmental program on account of services, supplies or care provided by Assignee to Assignor, including without limitation benefits for medical, health, property or related claims (Assigned Benefits), to the fullest extent permitted by applicable law.

1.2 Scope. The assignment includes the right to receive payment directly from any payor, to pursue, enforce and collect Assigned Benefits, to endorse or receive checks, electronic funds transfers or other remittances, and to pursue appeals, arbitration or litigation as necessary to secure payment.

2. AUTHORIZATION OF PAYMENT

2.1 Authorization. Assignor authorizes any insurer, plan administrator, third-party payor, or other entity responsible for payment to pay Assignee directly for Assigned Benefits up to the full amount of charges billed by Assignee, and to release to Assignee any information reasonably necessary to adjudicate, process or collect such benefits.

2.2 Payment Application. Any payments received by Assignee shall be applied first to outstanding balances for the services giving rise to the Assigned Benefits, in accordance with Assignee’s customary billing practices. Any remaining sums, if applicable, shall be remitted to Assignor within thirty (30) days of receipt, subject to any lawful setoff permitted hereunder.

3. REPRESENTATIONS AND WARRANTIES

Assignor represents and warrants that Assignor is the lawful policyholder, beneficiary or other person entitled to assign the rights set forth herein; that the information provided to Assignee regarding the policy, plan and claim is true and complete to the best of Assignor’s knowledge; and that there are no other assignments of the same benefits inconsistent with this Agreement except as disclosed in writing to Assignee.

4. OBLIGATIONS OF ASSIGNEE

Assignee shall exercise commercially reasonable efforts to submit claims, pursue payment, respond to inquiries and pursue appeals or disputes arising from denial or underpayment of Assigned Benefits. Assignee shall keep Assignor reasonably informed of the status of claim submissions and material communications with payors upon request.

5. COOPERATION

Assignor shall cooperate with Assignee in obtaining records, signatures, releases, or other information reasonably necessary to prosecute, appeal or collect Assigned Benefits, including execution of further documents reasonably requested by Assignee to effectuate this assignment.

6. PAYOR OFFSET, LIENS AND SETOFF

To the extent a payor has a lawful right of offset, lien, recoupment or subrogation against benefits, Assignee’s rights are subject to such lawful claims. Assignee shall notify Assignor of any asserted lien or third-party claim to Assigned Benefits and shall not unreasonably prejudice Assignor’s rights in defending such claims.

7. PRIVACY; AUTHORIZATION TO DISCLOSE

Assignor authorizes Assignee and its agents to obtain, use and disclose health, billing and claim information as necessary to submit claims, coordinate benefits, pursue appeals and collect Assigned Benefits. This authorization is valid for the period necessary to adjudicate and collect the assigned claims and is subject to applicable privacy laws.

8. INDEMNIFICATION

Each Party shall indemnify and hold the other harmless from and against any loss, liability, claim or expense, including reasonable attorneys’ fees, arising from its breach of this Agreement, its negligent acts or omissions, or its willful misconduct in connection with the exercise of rights or performance of obligations hereunder.

9. TERM; TERMINATION

This Agreement is effective as of the Effective Date and shall continue until the Assigned Benefits are fully paid or until earlier termination by mutual written agreement. Either Party may terminate this Agreement for material breach by the other if such breach remains uncured for thirty (30) days after written notice.

10. NOTICES

Notices to Assignor

Notices to Assignee

11. GOVERNING LAW; VENUE

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles. Venue for any action arising out of or relating to this Agreement shall be the state or federal courts located in the county in which Assignee maintains its principal place of business.

12. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and the Parties shall negotiate in good faith a substitute, valid provision that most nearly effects the Parties’ intent.

13. AMENDMENT; WAIVER; COUNTERPARTS

Any amendment or modification of this Agreement must be in writing and signed by both Parties. No waiver of any breach shall be effective unless in writing. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Facsimile or electronic signatures shall be deemed originals for all purposes.

ADDITIONAL INFORMATION

Assignor Date of Service (if applicable): . Estimated Amount Assigned: $.

ENTITY TYPE

Assignor Entity Type

Individual Corporation LLC Other

Assignee Entity Type

Individual Corporation LLC Other

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