Legal Assignment of Benefits

LEGAL ASSIGNMENT OF BENEFITS

This Legal Assignment of Benefits (the Agreement) is made effective as of by and between Assignor Name: (Assignor), and Assignee Name: (Assignee).

Assignor Address:

Assignee Address:

RECITALS

WHEREAS, Assignor is the holder of rights to certain benefits, insurance proceeds, claims, or recoveries arising from healthcare services, disability benefits, third-party liability claims, or other specified benefits related to the treatment or services described below; and

WHEREAS, Assignee provides healthcare services, treatment, supplies or administrative services and seeks to ensure payment directly from responsible payors or third parties for amounts due for services rendered to Assignor; and

WHEREAS, Assignor desires to assign and transfer to Assignee certain rights, claims and proceeds as set forth in this Agreement and Assignee desires to accept such assignment on the terms and conditions set forth herein.

NOW, THEREFORE

In consideration of the mutual covenants and other good and valuable consideration the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. ASSIGNMENT OF BENEFITS

1.1 Assignment. Assignor hereby irrevocably assigns, transfers and conveys to Assignee all rights, title and interest in and to any and all benefits, insurance proceeds, claims, causes of action, third-party liability recoveries, and payments (collectively, Assigned Benefits) payable for or on account of services, treatment or supplies provided by Assignee to Assignor through the Effective Date and for services authorized in writing by Assignor thereafter to the extent provided in this Agreement. This assignment includes the right to pursue, settle, endorse and receive payment of such Assigned Benefits.

1.2 Scope. Assigned Benefits shall include benefits under health insurance policies, managed care contracts, disability plans, automobile insurance, workers' compensation, liability policies, and any other applicable payor or responsible third party. Assignor expressly authorizes Assignee to apply for, file, prosecute and enforce claims for Assigned Benefits and to endorse checks, drafts or other instruments made payable to Assignor for Assigned Benefits.

2. AUTHORIZATIONS AND RELEASES

2.1 Authorization to Furnish Information. Assignor authorizes any insurer, payor, custodian of records, employer, claims administrator or other third party to release to Assignee any and all information, records or documentation necessary to pursue, adjudicate or collect Assigned Benefits, including medical records, billing records, claim files and payment histories.

2.2 Authorization to Pursue Claims. Assignor authorizes Assignee to pursue appeals, reconsiderations, administrative reviews, and legal actions necessary to obtain Assigned Benefits and to settle claims on behalf of Assignor to the extent the Assignee deems reasonable.

3. CONSIDERATION

In consideration for this assignment, Assignee agrees to apply Assigned Benefits to outstanding balances owed to Assignee for services rendered. Any amounts remaining after payment of Assignee's billed charges, liens, and agreed costs shall be handled in accordance with the parties' written agreement. Description of consideration or fee arrangement:

4. REPRESENTATIONS AND WARRANTIES

Assignor represents and warrants that (a) Assignor is the lawful owner of the rights and benefits assigned herein or is otherwise authorized to make this Assignment; (b) there are no prior assignments, liens, encumbrances or subrogation interests that would impair Assignee's rights except as disclosed in writing to Assignee; (c) all information provided to Assignee in connection with the Assigned Benefits is true, complete and accurate to the best of Assignor's knowledge; and (d) Assignor will not execute any other assignment of the same benefits without first obtaining Assignee's written consent.

5. PAYMENT PROCEDURES

5.1 Application of Payments. All payments received by Assignee for Assigned Benefits shall first be applied to Assignee's billed charges, reasonable costs of collection, and any liens or encumbrances required by law. Any remaining proceeds, if any, shall be disbursed as provided in a separate written agreement between the parties or as ordered by a court of competent jurisdiction.

5.2 Endorsement. Assignor authorizes Assignee to endorse or negotiate checks, drafts or electronic transfers made payable to Assignor for Assigned Benefits and to deposit such funds into accounts controlled by Assignee for the purpose of payment of charges described in Section 5.1.

6. BENEFIT TYPES (CHECK ALL THAT APPLY)

Medical / Healthcare Insurance    Disability Benefits    Workers' Compensation    Automobile Liability   

Other benefit type:

7. CLAIM IDENTIFIERS

Policy / Plan Name:   Policy / Plan Number:

Claim Number(s):

8. OBLIGATIONS OF ASSIGNEE

Assignee shall use commercially reasonable efforts to submit claims, pursue appeals, and endeavor to collect Assigned Benefits. Assignee shall provide written accounting to Assignor upon request showing funds received and disbursements made with respect to Assigned Benefits within a reasonable period following receipt of funds or upon final resolution of a claim.

9. INDEMNIFICATION

Assignor agrees to indemnify, defend and hold harmless Assignee and its agents, employees and contractors from and against any losses, liabilities, claims, costs and expenses (including reasonable attorneys' fees) arising out of any breach of Assignor's representations, warranties, or obligations under this Agreement or from any incorrect information furnished by Assignor.

10. TERM; TERMINATION

This Agreement shall commence on the Effective Date and shall continue until all Assigned Benefits have been collected and accounted for or until earlier terminated by mutual written agreement of the parties. Termination shall not affect Assignee's right to enforce any assignment made prior to termination.

11. NOTICES

All notices or communications required or permitted under this Agreement shall be in writing and shall be deemed given when delivered personally, sent by nationally recognized overnight courier, or sent by certified mail, return receipt requested, to the addresses set forth below or to such other address as either party designates by written notice to the other.

12. 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 dispute arising under this Agreement shall lie exclusively in the state or federal courts located in the county in which Assignee's principal place of business is located, unless otherwise agreed in writing.

13. 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, understandings and representations. If any provision of this Agreement is held to be invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and the invalid or unenforceable provision shall be reformed to the minimum extent necessary to make it valid and enforceable.

14. AMENDMENT; WAIVER; COUNTERPARTS

This Agreement may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right under this Agreement shall operate as a waiver of that right. This Agreement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

15. CERTIFICATION AND ACKNOWLEDGMENT

Assignor certifies that Assignor has read and understands this Agreement, that Assignor's execution of this Agreement is voluntary, and that Assignor has the authority to assign the rights and benefits herein. Assignor acknowledges that Assignee may rely on this Assignment in seeking and accepting payment from payors and third parties.

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