Assignment of Benefits
I HEREBY ASSIGN AND TRANSFER AN AND ALL RIGHTS, BENEFITS AND CAUSES OF ACTION TO THE ASSIGNEE. This is an assignment of my rights and benefit. In the event my insurance company is obligated to make payment to me upon charges made by the Assignee for its service and the company fails or refuse to make timely complete payments. I authorized Assignee to prosecute said cause of action either in my name or Assignee’s name and further to make timely, complete payment, I authorize Assignee to compromise, settle or otherwise resolve said cause of action as they see fit.
Direction of Payment
I hereby authorize and direct you, my insurance company and or my attorney to pay directly to Kentucky Injury Chiropractic and Rehabilitation (Assignee) such sums as may be due and owing Assignee for the service rendered to me both by reasons of accident or illness and by reason of any other bills that are due Assignee. I hereby authorize any insurance company to pay directly to Assignee the amount of this and or any future bills for service rendered to me and to release any information requested that is pertinent to my case to my insurance company or attorney involved in this case.
Letter of Protection in Favor of Provider
I hereby authorize and direct that my lawyer, if I am represented by counsel, SHALL withhold such sums from any disability benefit, medical payment benefits, no fault benefits, or any other insurance obligated reimburse me or from any settlement, judgment or verdict on my behalf as may be necessary to reimburse Assignee for service provided to me. I HEREBY FURTHER GIVE AN IRREVOCABLE LIEN to said Assignee against any and all insurance benefits named herein and any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by the Assignee. In the event that I do not have insurance coverage, I understand that I remain personally responsible for payment of service rendered; I also agree to pay in a current manner any difference between the total charges and the amount paid by the insurance company directly to Assignee.
PIP LOG & DEC Sheet Request
I HEREBY AUTHORIZE THE ASSIGNEE TO REQUEST A COPY OF THE APPLICABLE INSURANCE POLICY AND DECLARATION PAGE WHICH REFLECTS THE POLICY LIMITS AVAILABLE AT THE TIME OF THE ACCIDENT, AND THE APPLICABLE PIP LOG TO BE PROVIDED TO THE ASSIGNEE upon request. This request is authorized pursuant to the terms of my policy. I hereby authorize this assignee to request and received a copy of my PIP log periodically as they deem to be necessary.
Reservation of Benefits
Be further advised that I AM HEREBY PLACING YOU ON NOTICE THAT SHOULD YOU (THE INSURANCE COMPANY/CARRIER)DENY, REDUCE OR FAIL TO PAY ANY PART OF, OR AN ENTIRE BILL WHICH WAS SUBMITTED ON MY BEHALF FROM THIS PROVIDER, I(THE ASSIGNOR) AS WELL AS THE ASSIGNEEE ARE REQUESTING IN ADVANCED THAT YOU RESERVE OR SET ASIDE THE AMOUNT YOU REDUCED OF DENIED UNTIL THE DISPUTE IS RESOLVED. Should you submitted a check to Assignee which is less than the contractual amount and contains any language referring to payment ad “Full and Final Payment”, I have instructed Assignee to return the check to you (the carrier) and consider the bill still due and owing (a late payment). Additionally SHOULD THE REMAINING AMOUNT OF MY BENEFIT APPROACH AND THE AMOUNT WHERE THERE WOULD BE INSUFFICIENT FUNDS TO PAY THE AMOUNT YOU REDUCED, DENIED OR FAILED TO PAY, PLEASE NOTIFY ME (THE ASSIGNOR) AND THE ASSIGNEE OF THIS FACT. Should my benefits exhaust; please notify me (the assignor) and assignee promptly.
If any term or provision of this Assignments, Lien and Authorization of the application thereof to any person or circumstances shall to any extend be invalid or unenforceable the remainder of this Assignment, Lien and Authorization or the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby, and each term and provision of this Assignment, Lien and Authorization shall be valid and enforced to the fullest extent of the Law.
_____________________________ ___________________________________ ______________
Print Patient Name Patient Signature Date