Medpay Release Form

MEDPAY RELEASE FORM

This Medpay Release Form (the "Release") is made effective as of by and between Claimant Name: (hereinafter "Claimant") and Payer/Insurer Name: (hereinafter "Payer").

RECITALS

WHEREAS, on or about (the "Date of Loss"), Claimant sustained injuries for which medical expenses were incurred; and

WHEREAS, Claimant submitted claims for medical payments coverage (Medpay) under policy number and claim number ; and

WHEREAS, Payer has agreed to pay or has paid Medpay Benefits to Claimant in the total amount set forth below in full or partial satisfaction of medical expenses related to the Date of Loss.

NOW, THEREFORE

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

1. DEFINITIONS

For purposes of this Release, "Medpay Benefits" means payments made by the Payer specifically intended to reimburse or pay for medical, hospital, diagnostic, rehabilitative, chiropractic, pharmaceutical or related health-care services arising from the Date of Loss.

2. PAYMENT DETAILS

3. RELEASE AND DISCHARGE

Upon receipt of the Total Medpay Amount Paid identified above, Claimant fully and finally releases, acquits and forever discharges Payer, its affiliates, agents, employees, successors and assigns from any and all claims, demands, causes of action, rights of recovery, liens or subrogation rights to the extent of such Medpay Benefits paid. This Release applies to past, present and future claims for medical expenses arising from the Date of Loss to the extent covered by the Medpay Benefits.

4. ASSIGNMENT OF RIGHTS

To the extent permitted by applicable law, Claimant hereby assigns to Payer any rights, claims or causes of action Claimant may have against third parties for recovery of amounts equal to the Medpay Benefits paid by Payer. Such assignment is limited to the amount of Medpay Benefits paid and Claimant shall cooperate with Payer in the prosecution and enforcement of any assigned rights.

5. AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Claimant authorizes all treating health care providers to release any medical records, billing records, insurance information and other documents reasonably requested by Payer, its representatives or counsel related to treatment for the Date of Loss. This authorization shall remain in effect for a period of two (2) years from the Effective Date unless earlier revoked in writing.

6. SUBROGATION AND REIMBURSEMENT

If Claimant recovers from any third party, by settlement, judgment or otherwise, amounts for medical expenses arising from the Date of Loss, Claimant shall reimburse Payer up to the amount of Medpay Benefits paid. Reimbursement shall be made promptly upon receipt of recovery and shall be net of reasonable and documented litigation costs directly associated with obtaining such recovery, unless otherwise agreed in writing by the parties.

7. INDEMNIFICATION

Claimant shall indemnify, defend and hold harmless Payer from any claims, demands or causes of action asserted by third parties, including medical providers, to the extent such claim arises from Claimant's breach of this Release or the inaccuracy of representations made herein.

8. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that Claimant is the person entitled to recover Medpay Benefits, that the information provided to Payer is true and complete, and that Claimant has not assigned, except as set forth herein, any rights to the Medpay Benefits that would impair the effectiveness of this Release.

9. NOTICES

All notices required or permitted under this Release shall be in writing and delivered by hand, certified mail, return receipt requested, or overnight courier to the addresses below or to such other address as either party may designate by notice:

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Release shall be governed by and construed in accordance with the laws of the state specified by the parties: Governing State: . This Release contains the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings and agreements. If any provision of this Release is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Release shall be effective unless in writing and signed by both parties. Failure by either party to enforce any right under this Release shall not constitute a waiver of that right. This Release 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.

IN WITNESS WHEREOF, the parties have executed this Medpay Release Form as of the Effective Date first written above.

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