ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND/OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE.
I hereby assign and convey directly to Dr. Clayton Frenzel, P.A., BodEvolve LLC, AC Surgery Center LLC, Keystone Partners PLLC as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named healthcare providers, 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 hereby authorize the above-named healthcare providers to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named healthcare providers all Plan documents, summary benefit descriptions, insurance policy(s), and/or settlement information upon written request from the above-named healthcare providers or its attoneys 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 healthcare providers any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named healthcare providers (including any right 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 assignment and designation of authorized representative to convey to the above-named providers 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 healthcare providers including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (abovenamed providers) 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 or 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 action or right against any liable party, insurance company, employee benefit plan, healthcare benefit plan, or plan administrator. The above-named providers as my assignee and my designated authorized representative may sue any such healthcare 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 (healthcare reform 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 also herby authorize the release of any medical information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries, and request payment of my medical insurance benefits to be paid directly to Dr. Clayton Frenzel, P.A., BodEvolve, LLC.
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.