ASSIGNMENT OF ALL RIGHTS AND BENEFITS:
In exchange for and in connection with any and all of the medical and related (“services”) provided to me by Jason Cuellar, M.D., LLC. (“Physician”), I hereby assign to Physician all of my rights, benefits, privileges, protections, claims and any other interests of any kind whatsoever, without limitation, that I had, have or may have in the future pursuant to or in connection with any insurance policy or plan, health benefit plan, health management agreement, risk-bearing agreement, trust, fund or any other source of payment, insurance, indemnity or health or medical coverage of any kind (collectively, “Health Coverage”).
This assignment includes, without limitation, direct payment by my insurance carrier or health plan directly to Physician and/or its designated associates for the Services, appeal rights (both internal and external), fiduciary rights, rights to sue, rights to payment, rights to full and fair claims review, rights to penalties or interest, rights to plan documents and plan information, and rights to notices and disclosures from any source (collectively, “Rights”). I am here by transferring to Physician all of these Rights under any Health Coverage to which I am now, previously, or may be entitled to in the future with respect to the Services. Unless otherwise agreed between me and Physician, this assignment is irrevocable.
APPOINTMENT OF AUTHORIZED REPRESENTATIVE:
I hereby designate Physician and/or Physicians’ designated agents and representatives as my duly authorized representative(s) in connection with all matters arising from or relating to Rights and Health Coverage, such that Physician completely and without reservation “stands in my shoes” and takes my place for all applicable purposes, and is granted absolute power and legal authority to seek, claim and directly receive payment or reimbursement for Services; challenge or appeal any adverse benefit determination of any kind whatsoever; or take any other action or obtain anything that I would have been entitled to do, seek, claim, appeal or obtain in my own capacity pursuant to or in connection with the Rights or Health Coverage in any legal, private, administrative, formal or informal process or forum whatsoever and without limitation, including any internal or external appeal, review, grievance or any other process, procedures or entitlement under any Health Coverage.
AGREEMENT TO COOPERATE:
I hereby agree to personally cooperate with, and take all steps necessary, required or reasonably requested by any Health Coverage or by Physician (or its designated associates) to effectuate, perfect, confirm, validate or enforce my Assignment of Rights and Benefits to Physician or authorization of Physician as my authorized representative, as provided above. I promise to make my best efforts to assist and cooperate with Physician as needed or reasonably requested by Physician in connection with any action in any forum, whether legal, formal or informal, without limitation, commenced or maintained by Physician in order to exercise, secure or enforce any Rights provided under the Health Coverage.