ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATD WITH MY HEALTH INSURANCE AND/OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED RESPRESENTATIVE
DR H. STEVE BYRD, DR. A. JAY BURNS, DR. RICHARD Y. HA, DR. JOHN L BURNS, AND DR. MATTHEW TROVATO
I hereby assign and convey directly to the above named health care provider, as my designated authorized representative, all medical benefits and/or medications rendered or provided insurance reimbursement, if any, otherwise payable to me for the services, treatments, therapies, and/or medications rendered or provide by the above named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I nearby authorize the above named heath care provider to release all medical information necessary to process my claims. Further, I herby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above named health care provider any and all plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above named health care provider or its attorneys in order to claim such medical benefits.
In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort reason insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above named health care provider (including any rights to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.
I intend by this agreement and designation of authorized representative to convey to the above named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies and/or medications provided by the above named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breath of fiduciary duty claims). The assignee and/or designated representative (above named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts of law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in actions or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above named provider as my assignee and my designated authorized representative my bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider’s expense.
Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.