Academy of Chiropractic’s Lawyers PI Program

Office Systems & Admissibility #21

From the Desk of :

“Assignment of Benefits & Rights”

Circa 2015

Most of you have assignment documents and they work. However as the insurance landscape evolves with the Affordable Healthcare Act, new language should be considered. In addition, MOST of you DO NOT HAVE assignment of rights concurrently and that is both problematic and a MUST.

I had previously posted a sample letter in section #14 “Forms and Communications,” this is the next generation. 

You are a third party to the contract between the insurance carriers and your patients, therefore you need a further contract from your patient that allows you to have the RIGHT to contact the insurance company on behalf of the benefits that have been assigned to you. Without an assignment of rights, the carriers have strong legal standing NOT to talk to you because you have no right without an assignment of those rights. In the past, many carriers have not enforced the absence of that document , but today and in the near future many carriers will consider the lack of appropriate documentation a valid reason for another profit center (aka… keeping your money because they can). 

This is about you never being the reason for not getting paid over technicalities. 

The following document was created by a former judge in Georgia that appears to be in a universally accepted format and should be accepted in every state. HOWEVER… I urge you (my disclaimer) to check with a local lawyer to ensure it meets your state’s statutory requirements. The suggested language is as follows: 


                I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay: Precision Pain Relief Center, Spine & Injury Center located at 123 Main St., Anytown Ga 33333 , as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided.

                I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under.

                I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same.

                I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA plan, PPACA plan, or insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies).  I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our representative, ERISA representative, or PPACA representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and/or payments that are due to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan or insurer.  I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment and/or designation will remain in effect unless revoked in writing. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

Signed this ______ day of _________________ 20 ____.



                                                                                                                (Patient signature)


                                                                                                     (Please print patient name)


(Signature of Guardian if applicable)