Personal Injury Patient Intake Form

ASSIGNMENT OF BENEFITS & AUTHORIZATION FOR DIRECT PAYMENT

I hereby assign all applicable medical and/or insurance benefits to CarePath Injury Centers for services rendered in connection with my Workers’ Compensation (WC) / Motor Vehicle Accident (MVA) claim. I authorize direct payment to CarePath Injury Centers from my insurance carrier or any responsible third party payer.

I understand that this assignment of benefits does not relieve me of financial responsibility for any charges not covered by my insurance, including but not limited to co-payments, deductibles, denied claims, or limitations on coverage. I agree to cooperate with CarePath Injury Centers & my legal teams in any necessary efforts to secure payment, including but not limited to providing additional information, signing required documents, or pursuing appeals for denied claims.

Release of Information:
I authorize CarePath Injury Centers to release any medical records, reports, or other necessary information to my insurance carrier, legal representatives, and other involved parties for the purpose of claim processing, billing, and reimbursement.

Lien & Third-Party Reimbursement Agreement (if applicable):
I understand that if my claim is subject to litigation or settlement, I authorize my attorney to make payment directly to CarePath Injury Centers for any outstanding medical bills from settlement proceeds. I agree to inform CarePath Injury Centers of any changes regarding my legal representation, insurance coverage, or claim status.

Acknowledgment & Signature:
By signing below, I confirm that I have read and understood this Assignment of Benefits

I hearby give CarePath Injury Centers of Pennsylvania permission to request and receive medical, imaging, and other associated records from other institutions that I have visited, been seen or been a patient at for my accident/injury. They may request records on my behalf and receive them to utilize for my care plan with them moving forward.