EnglishInsurer please read the following in its entirety upon receipt:
I, the undersigned patient/insured knowingly, voluntarily and intentionally assign the benefits of insurance and any overdue interest payments under the policy of insurance from my insurer or the responsible insurer to the above described medical provider for any and all services rendered to the undersigned patient/insured.
The patient understands it is the express intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered. The undersigned assigns any and all claims for statutory bad faith to the above medical provider. If the insurer disputes the validity of this assignment of benefits then the insurer is instructed to notify the provider in writing within five (5) days of receipt of this document.
I understand this assignment will remain in full force and effect and will NOT be revoked unless the revocation is agreed to by both the medical provider and the undersigned patient or the patient's attorney. This assignment applies to both past and future medical expenses and is valid even if undated.
A photocopy of this assignment is to be considered as valid as the original. The undersigned patient/insured directs the insurer to pay the medical provider directly without including the patient's name on the check.
The insurer is directed by the provider and the patient/insured to not issue any checks or drafts in partial settlement of a claim that contain or are accompanied by language releasing the insurer or its insured/patient from liability unless there has been a prior written settlement agreed to by the medical provider and the insurer as to the amount payable under the insurance policy or contract.
The provider hereby objects to any reductions or partial payments made at the discretion of the insurer. Any partial or reduced payment regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted.
In the event the subject medical benefits are disputed by the insurer for any reason, including but not limited to, medical reasonableness and/or necessity, the undersigned patient/insured hereby instructs the insurer to set aside any amount disputed (i.e. to escrow the money) and not pay the disputed amount to anyone, including myself, or any entity until the dispute is resolved. The insurer is instructed to immediately explain in writing to the above provider of any dispute. If the insurer schedules an IME or EUO the insurer is hereby requested and authorized to send a copy of said notification to this provider. The provider is not the agent of the insurer or the patient for any purpose.
The undersigned patient/insured agrees to pay any applicable deductible or co-payments for services rendered after the policy of insurance exhausts, and for any other service unrelated to the automobile accident.
Release of Information
I hereby authorize this medical provider to: furnish my insurance company or companies and the patient's attorney with any and all information that may be contained in my medical records; to obtain coverage information telephonically from my insurer; to request a written non-redacted PIP payout sheet from the insurer; and to obtain copies of my medical records, including but not limited to, documents, reports, scans, notes, opinions, X-rays, and MRI s, from any other medical provider or any insurance company. The insurer is directed to keep the patient's medical records private and confidential. The insurer is NOT authorized to provide these medical records to anyone, including but not limited to, third party vendors without the patient's and the provider's prior express written permission.
I give my permission to My Vital View / Beach Medical Specialists and their staff to release my medical information to their related companies, subcontractors and affiliated third parties as necessary to manage my account and health data.
I certify that I have not been solicited or promised anything in exchange for receiving medical care or that I have received any promises or guarantees from anyone as to the results that may be obtained by any medical treatment.
If you do not completely understand this document please ask us to explain it to you. If you electronically accept we will assume you understand and agree to the terms.
My Vital View / Beach Medical Specialists
