Assignment of Benefits & Payment Responsibility to (Provider 1, Title), (Provider 2, Title), (Provider 3, Title), Provider 4, Title) and ORLANDO RESORTS SPINE AND BODY (referred to as "Providers")
Legal Assignment of Insurance Benefits: In exchange for and in connection with any and all of the service(s) provided to me ("Services") by Providers, I hereby Irrevocably assign to Providers all of my rights, benefits, privileges, protections, claims, and any interests of any kind whatsoever, without limitation, including, but without limitation, direct payment to Providers for the Services, appealing rights, rights to fiduciary duties, rights to sue, rights to payment, rights to penalties or interest, rights to plan documents, and rights to Information, notices, and disclosures from any source, (collectively "Rights") that I had, have or may have In the future pursuant to or in connection with any Insurance plan, health benefit plan; trust, fund, or any other source of payment, insurance, indemnity or health or medical coverage of any kind (collectively "Health Coverage"), such that I am hereby transferring all and retaining none of these Rights under any Health Coverage to which I am now, previously, or may be entitled to in the future. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, I Instruct my applicable Insurance plan, health benefit plan, trust, fund, or any other source of payment, insurance, Indemnity, or health or medical coverage of any kind to please advise and disclose to Providers In writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment Is waived on any pending claims for benefits under the respective policies. I agree that, should the amount received be insufficient to cover the entire claim I will be responsible for payment of any coinsurance and/or deductible that remains unpaid by my health Insurance company, workman's compensation plan, and/or auto accident insurance; I will be responsible to Providers for payment of the entire invoice. 2. Denial of Claim: I understand that Providers will make every effort to obtain payment of all health care services or products provided by providers from my Insurance company. I agree that I will be jointly and severally financially responsible for any portion of the Providers invoice that Is not paid; I understand that I am responsible for any health insurance deductibles and co-payments; 0 hereby irrevocably assign the benefits payable for any services rendered by Providers to me and authorize Providers to submit a claim to any medical Insurance company that I may have for payment to Providers. 3. One Time Claim Submission: I understand that Providers will make every effort to obtain payment for all services and or products provided by workman's compensation plan and/or auto accident Insurance, Providers will look to me for payment of any Providers services and/or products supplied to me. I agree that I will be jointly and severally financially responsible for any portion of the claim, in whole and in part, that is not paid. 4. I certify that the Information given by Patient to Providers In applying for payment to my workman's compensation plan and/or auto accident Insurance or any other medical Insurance that I may have, is correct. I agree that if assigned insurance benefits owed to Providers by me are paid to me, I shall Immediately notify Providers of such, and immediately endorse benefits check to Providers. 5. Appointment as Authorized Representative And Right to Sue: I hereby designate Provider's as my duly authorized representative In connection with all matters arising from or relating to Services, Rights and Health Coverage, such that Providers completely and without reservation stands in my shoes and takes my place for all purposes, and is granted absolute power and legal authority to do, seek, claim, appeal 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 Services, Rights or Health Coverage, In any appeal, review, grievance, or any other process, procedure or entitlement under any Health Coverage. 6. Agreement to Cooperate: In addition, I hereby agree to personally cooperate with, and take all steps necessary, required or reasonably requested by, and Health Coverage, to effectuate, perfect, confirm or validate my assignment and/or authorization of Providers as my authorized representative, and I promise to assist and cooperate with Providers as a needed or reasonably requested by Providers In connection with any action In any forum, whether legal, formal or informal, without limitation, commenced or maintained by Providers in connection with the Services or relating to any Rights provided under Health Coverage. I understand that, In the event I don't fulfill any of the above obligations, I will remain personally liable for payment of the Services to the extent of the law.
By signing below, I acknowledge my authorization of treatment and receipt of all documentation in accordance with my treatment.