Common Contracts
2 similar Assignment of Benefits Agreement contracts
ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • January 15th, 2015
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 Liberty Mutual Insurance Company. This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I acknowledge that the medical provider’s failure to honor the obligations set forth below render this assignment void. Nothing in this assignment authorizes the medical provider and/or its agents to pursue a claim for bodily injuries on my behalf. Furthermore, I authorize the release of medical records to the insurer and a photocopy of this document shall be considered as effective and valid as the original.
ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • January 15th, 2015
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 Liberty Mutual Insurance Company. This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I acknowledge that the medical provider’s failure to honor the obligations set forth below render this assignment void. Nothing in this assignment authorizes the medical provider and/or its agents to pursue a claim for bodily injuries on my behalf. Furthermore, I authorize the release of medical records to the insurer and a photocopy of this document shall be considered as effective and valid as the original.
