Authorization for Assignment of Benefits
Please accept this Assignment of Benefits as a blanket Assignment of Benefits for chares on services rendered and submitted by, NJPSSA, on my behalf I, the undersigned, authorized and request that
(please print your insurance name here)
For such services as listed above, change the assignee and make payment for benefits which may be due herein to: NJPSSA, LLC
MEDICAL HISTORY FORM
Have you ever had or been told you have (check all that apply)
ROS: Please check the box if you currently have any of the following
Social/ Family History:
7. Describe Accident Including Causes and Surrounding Circumstances
MEDICAL HISTORY FORM (CONTINUED)
8. Please mark the area(s) in the diagram below where you are having pain:
MEDICAL HISTORY FORM (Continued)
Previous Medications Tried:
Please list if you have any Allergies:
Please list all previous Surgeries:
Medications you take at home (including pain medicines)
ASSIGNMENT OF BENEFITS
1. I , the undersigned, hereafter referred to as "the patient" do hereby assign all of my rights and interests to NJ Pain, Spine & Sports Associates, hereafter referred to as "the medical provider" to pursue and obtain payment on my behalf. This assignment shall include but is not limited to, all rights available to me pursuant to the Personal Injury Protection Statutes of the State of New Jersey.
2. I, assign, to the medical provider, all my rights and benefits under the insurance contract for payment for services rendered to me. However, upon consent of both parties, same shall be revocable.
3. I, the patient, do hereby understand and acknowledge that if I willfully refuse to comply with reasonable requests of the insurance carrier, payment of my medical bills may be denied and I will be held responsible for same.
4. I, the patient, authorize my bodily injury attorney to pay directly to the medical provider any monies due on my account, or, have same deducted from any settlement made on my behalf.
5. I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health carrier and/or other insurance carrier fails to forward the check to the medical provider, I will endorse and sign the check to the medical provider within (5) days of receipt of same.
6. I, the patient, do hereby acknowledge that I will not file suit and/or arbitration for the payment of the above provider’s medical bills unless I am requested to do so by the medical provider. I understand that the above referenced medical provider has an attorney and will collect payment on my behalf from the insurance carrier.