Patient Health History - Intake Form (Page 6 of 8) in pdf

Pain Management Associates

Assignment of Benefits and LTD Power of Attorney

I hereby assign benefits and authorize payment directly to Pain Management Associates and/or its staff (hereinafter

collectively "You") of any insurance benefits made as payment to me (or a minor for whom I am guardian) as reimbursement

for services provided to me(or a minor for whom I am the guardian) for their services. I agree to immediately forward to

this office any insurance payments which are made directly to me.

, irrevocably assign to you, Pain Management

Associates, my medical provider, all of my rights and benefits under my insurance contract for payment for services

rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically

included filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably

authorize you to retain an attorney of your choice on my behalf for collection of your bills. I direct that all reimbursable

medical payments go directly to you, my medical provider. I authorize you to act on my behalf. I consent to your acting

on my behalf in this regard and in regard to my general health insurance coverage pursuant to the "benefit denial

appeals process" set forth in the NJ Administrative Code. I request that the insurance carrier consent to my assignment

of benefits Within 10 days of receipt otherwise it is deemed consented to.

As a medical provider I agree to attempt to reasonably comply with the PIP carrier's decision point review/pre-certification

plan and to hold the patient harmless if I fail to comply with same, in consideration for the carrier's consent to this

assignment.

In the even the insurance carrier responsible for making medical payments in this matter does not accept my assignment,

or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and

authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against

the carrier in this case in my name including filing an arbitration demand or lawsuit. I specifically authorize that attorney to

file directly against the carrier in my name or in your name as a medical provider rendering services to me and designate

your collection agency as my attorney in fact. I further grant limited power of attorney to you as my medical provider

to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter and

hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me.

I authorize you and your attorney to obtain medical information regarding my physical condition from any other health

care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to

release call such information to you about me, including medical reports, X-ray reports, narrative reports, and any other

report or information regarding my physical condition.

I understand that I am responsible for all fees charged, whether they are covered by insurance or not. Also, I am aware it

is my personal responsibility to monitor insurance payments and maximums. If I receive any payment from an insurance

carrier relating to the services rendered, I agree that I will hold such payment in trust for

and

I also agree to send such payment to

within one week after receipt of same. I also

agree to pay attorney’s fees equal to 33 1/3% of the outstanding balance, plus court costs, in the event the account is

turned over to an attorney for collection

Patient's Signature:

Date:

Patient's Name (printed):

Patient Health History - Intake Form Page 6