Common Contracts
1 similar Assignment of Benefits Agreement contracts
ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • May 28th, 2014
I, (the patient) hereby assign my right to pursue a claim for reimbursement of Personal Injury Protection Benefits rendered by the medical provider who has signed this agreement (or designated an authorized representative to sign on his/her behalf) and his/her employees under the applicable insurance policy against Mercer Insurance Company (members of United Fire Group). This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I
