For and consideration of NEUSPINE INSTITUTE LLC agreeing to provide me with medical care and related services and not requiring prepayment for rendition of services, I hereby irrevocably assign all rights and benefits I have to NEUSPINE INSTITUTE LLC for Personal Injury Protection and Medical Payment Coverage, and other benefits which I may have according to Florida Statute § 627.736. This includes any benefits from my insurance company and any other entity that may be responsible for medical bills I incur. I further authorize NEUSPINE INSTITUTE LLC to collect payments & prosecute any necessary actions to collect payments for services as it sees fitin accord with law. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF RIGHTS AND BENEFITS.
This assignment concerns only the bills for NEUSPINE INSTITUTE LLC and those costs including, but not limited to, attorney’s fees, other costs, and interest necessary in procuring payment from the above-names insurance company and/or other entities. This assignment is not intended to assign any other causes of action that may belong to the undersigned patient, nor does it delegate any duties of mine. I agree to pay any applicable deductible or copayment not covered by any policy of insurance. I understand that as a benefit and convenience to me, NEUSPINE INSTITUTE LLC may pursue collection against the insurance company or other responsible entity for itself or on my behalf, at its election. I hereby instruct and direct my insurance company/companies to pay my benefits directly to NEUSPINE INSTITUTE LLC at the address provided on the bill(s). If my current policy prohibits direct payment to doctors or healthcare providers, then I hereby instruct and direct my insurance company or other responsible entity to make the check payable to me and mail it to NEUSPINE INSTITUTE LLC at the address on the bill, and I hereby authorize NeuSpine Institute to endorse any such instrument of payment with my name and negotiate or deposit it to NeuSpine Institute’s account, at NeuSpine Institute’s election. I agree that NEUSPINE INSTITUTE LLC is providing me healthcare services that I have sought out for my benefit, at charges I hereby determine to be reasonable to me, and that the care / services I seek from NeuSpine Institute are reasonable and medically necessary from my perspective.
I instruct my insurance carrier(s) to pay these bills to the full extent of my available benefits under the insurance policy and Florida law. If any portion of the charge for these services is either reduced or denied in whole or in part, my insurance company or other entity is to place funds equal to the amount of the reduced or denied charges into escrow and hold the escrowed funds until agreement or resolution of legal action by NEUSPINE INSTITUTE LLC. I further instruct my insurance company to make payment for charges submitted by NEUSPINE INSTITUTE LLC in priority to any other request to escrow benefits, including a request by myself to reserve benefits for pending disability claims. I hereby give NEUSPINE INSTITUTE LLC a limited power of attorney to endorse and sign my name on any draft or other instrument for payment to either NEUSPINE INSTITUTE LLC or myself if said draft represents payment for charges related to services rendered by NEUSPINE INSTITUTE LLC, and in any event, to negotiate any and all such payments for the account and benefit of NeuSpine Institute.
I further direct my insurance carrier as the responsible entity to provide information to NEUSPINE INSTITUTE LLC which is otherwise available to me including but not limited to information relating to any copay under any applicable insurance policy, declaration page, all applicable endorsements, transcripts and/or copies of any recorded statements and examinations under oath and requests for same, independent medical evaluations and requests for same, and peer review reports. This request includes the name and address of other medical providers to whom payments have been made under my policy/policies of insurance. If any language within this agreement has the effect of invalidating this agreement, that language shall be deemed revised to the extent necessary to render such binding and effective under Florida Law, and the remainder of the assignment shall maintain full force and effect. A photocopy or electronic copy or transmittal of this assignment shall be considered as effective and valid as the original.
I am responsible for copays, co-insurances, and deductibles prior to my office visits and surgery date(s) if surgery is necessary.
Direction of Payment
I hereby authorize and instruct any insurance company or attorney to pay directly to Assignee the amount of all bills for services rendered. Without limitation of any other terms of this assignment or any other agreement with the Assignee, I also agree to pay in a current manner any difference between the total charges and the amount paid by the insurance company directly to Assignee. This assignment also allows Assignee to endorse any check or draft provided to Assignee in my name for purposes of payment for services rendered to me by Assignee or its employees, contractors, or agents.
PIP Log & Declaration Sheet Request
I hereby authorize Assignee to release requested information, which is pertinent to my case or condition(s), to my insurance company or any/all of my attorneys now or hereafter involved in this case, pursuant to 627.4137 Florida Statutes. I hereby request that a copy of the pip log and declaration sheet, which reflects the policy limits available at the time of this accident, be provided to this Assignee. I hereby authorize this Assignee to request and receive a copy of my pip log periodically as Assignee deems necessary. If any term or provision of this Assignment, Lien, and Authorization or the application thereof to any person or circumstance shall, to any extent, be determined to be invalid or unenforceable, the remainder of this Assignment, Lien, and Authorization, or the application of such term or provision to persons or circumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby, and each term and provision of this Assignment, Lien, and Authorization shall be valid and enforced to the fullest extent of the law.
Reservation of Benefits
Be further advised, I am hereby placing you on notice pursuant to Florida case law that should you (the insurance company/carrier) deny, reduce, delay, or fail to pay any part of or the entire bill which was submitted on my behalf from this health care provider, I (the assignor) as well as the assignee (health care provider) are requesting, in advance, that you reserve, or “set-aside,” the amount reduced or denied or delayed until the dispute is resolved. Should you submit a check to this health care provider which is less than the correct contractual amount, and it contains any language referring to or purporting to declare payments as “Full and Final Payment,” or the like, then I have instructed this health care provider to return the check to you (the insurer) and consider the bill still due and owing (i.e. a late payment as defined in F.S. 627.736). Additionally, should the remaining amount of my benefits approach an amount where there would be insufficient funds to pay the amount you reduced, delayed, or failed to pay, please notify me (the assignor) and this health care provider (the assignee) immediately.
Health Care Provider: NeuSpine Institute, LLC ("NeuSpine Institute")