Assignment, Authorization and Lien
I, hereby authorize and direct my insurance company and /or my attorney, to pay directly to The Brooks Accident & Injury Clinic such sums as may be due and owing this office an assignee for services rendered the undersigned, by reason, of accident or illness, and by reasons of any other bills that are due or may become due, and to withhold such sums from any disability benefits, including, but not limited to foundation grants, governmental or agency benefits, medical payments benefits. No fault benefits, health and accident benefits, worker’s compensation benefits, or any other insurance benefits obligated to reimburse the undersigned or from any settlement, judgment or verdict on my behalf as may be necessary to adequately provide for any financial obligation owed to this office and assignee.
The parties further agree that, in the event my insurance company obligated to make payments to me upon charges made by this office and assignee for its services refuses to make such payments, this agreement is to act as an assignment of the undersigned rights and benefits to the extent of the office’s services provided; therefore, I hereby assign and transfer to this office and assignee any and all causes of action that I might have or that might exist in my favor against such company and authorize this office and assignee to prosecute said cause of action either in my name or in the assignee’s name and further I authorize this office and assignee to compromise, settle, or otherwise resolve said claim or cause of action as they see fit.
I hereby further give a lien to said office against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgment or verdict which may be paid to the undersigned as a result of the injuries or illness for which I have been treated by said office and assignee. The undersigned patient and assignee further agree that the assignee’s right for payment from the undersigned patient shall be tolled by any statute of limitation until a reasonable time has lapsed after either negotiations or litigation between third parties and the undersigned patient are resolved.
It is further agreed that the undersigned patient shall remain personally responsible for the total amounts due to this office and assignee for its services. This office an assignee for and in consideration of their rights for immediate payment on the
indebtedness owed at this time and which may become due in the future agrees to forego collections of the aforementioned monies owed for a reasonable length of time. This assignee, however, reserves the right to revoke this agreement upon thirty (30) days written notice to the undersigned patient this assignee demands payment after said notice has expired.
I authorize this office to release any information pertinent to my case to any insurance company, adjustor, or attorney to facilitate collection under this assignment, lien, and authorization. I agree that the above mentioned office by given power of attorney to endorse and/or sing my name on any and all checks for payment of any indebtedness owed this office and assignee.
I do attest that I have come to this clinic for purposes of acquiring medical care. I am here for my medical problems and have no intent to mislead or defraud my treating practitioners in any way that might result in inappropriate charges to third party payers, federal, state, or local government, or insurance carriers. Further I attest that my injuries are real and that I am in pain and in need of medical treatment as a result of the medical condition for which I am consulting The Brooks Accident & Injury Clinic. I also attest that I understand the context of this statement with complete comprehension of its content.
Referral To The Brooks Clinic