Irrevocable Provider/Patient Assignment, Lien, Power of Attorney, Document/Records Release, and Payment Agreement
THIS IRREVOCABLE, NON-RESCINDABLE, AGREEMENT and ASSIGNMENT OF LIEN INTEREST/BENEFITS is entered into this date by and between the above named patient, hereinafter called "Patient", and Elevate Health Clinics, hereinafter called “Provider”.
WHEREAS, Patient desires to receive health care services from Provider and requests that Provider provide such services, but defer payment on the part of Patient for such services until Patient secures his/her Insurance settlement proceeds. In consideration of Provider's willingness to agree to such terms Patient does hereby: irrevocably g rant a medical lien to the Provider and assign the following rights and benefits to Provider as the legal consideration and inducement to cause Provider to forego its legal right to require payment upon provision of services and wait for the payment of such benefits from Patient until such time that Patient’s legal claims against at-fault party is resolved either through litigation and/or negotiations, It Is hereby agreed:
SECTION 1. Patient hereby irrevocably acknowledges financial responsibility for all reasonable and necessary medical services provided to patient by Provider as consideration for such Provider services. If at any time, the Patient is not represented by a licensed attorney in a claim against the at-fault party or an insurance carrier, then the Patient irrevocably assigns to Provider any and all legal claims against the party or parties that gave rise to Patient's claims for damages for which Provider has been engaged to provide healthcare services, including Patient's legal entitlement to monetary proceeds due to be paid by or through any health insurance, liability, PIP or medical payment Insurance coverage that is/are maintained by Patient or under which Patient derives some legal entitlement arising as a result of the injuries suffered from an automobile accident, for which Provider has rendered the above described health care services. Patient irrevocably grants, conveys and assigns to Provider a monetary Interest and lien upon the proceeds of Patient's personal injury claim against the person(s) or party(les) responsible for Patient's Injuries in the exact amount necessary to pay the reasonable charges for the necessary treatment to alleviate Patient's injuries rendered by Provider. Patient's lien interest granted and conveyed to Provider shall extend from any automobile medical payment coverage maintained by Patient or any person under whose policy of Insurance Patient may have a lawful right of recovery, (ii) any and all benefits, claims and/or causes of action, payable by or under any third party liability insurance coverage to which Patient may have a right of recovery due to the services rendered by Provider, and (iii) a "common law lien Interest" in, and all contractual rights and claims to, any and all insurance proceeds to which Patient has or maintains a legal entitlement, to be paid by or from any Insurance company, health care benefit plan, or any other party contractually liable for payment of all or any portion of the charges for health care services rendered by Provider to the Patient as a result of the injuries sustained by Patient. This irrevocable assignment of benefits, conveyance and assignment of lien interest and conveyance and assignment of contractual rights to and for those charges attributable to Provider's health care services shall extend to, but not be limited to, Provider's entitlement to any and all claims, causes of action and insurance proceeds remitted as a result of any insurance claim for damages by the Patient which has given rise to the above referenced health care services provider by Provider, as recognized under the holdings of Ford Motor Credit Co, v, Allstate, 2 S.W. 3d 810 (Mo^pp.W.D. 1999) and Marvin's Midtown Chiropractic Clinic, LLCv. State Farm Mutual Automobile Insurance Company. 142 S.W. 3d 751 (Mo.App, W.D. 2004). Patient consents to Provider sending their file to a potential new legal representative in the case of dissolution of their current legal representation.
This irrevocable assignment of benefits and lien Interest shall extend to the total amount of reasonable and customary charges incurred by Patient for services rendered by Provider. Patient agrees that full payment for all services rendered by Provider is due upon receipt of said services and Patient accepts full financial responsibility for payment for such services. Patient acknowledges that Patient is ultimately financially responsible for the payment of all reasonable and necessary medical services that Patient receives from Provider regardless whether any portion of those fees and charges due to be paid by Patient to Provider are paid through insurance proceeds to which Patient has asserted a claim. Patient acknowledges that Provider's acceptance of Patient's irrevocable assignment of benefits and lien interest is a convenience to Patient, and that Provider may revoke this assignment and lien interest at any time.
SECTION 2. If at any time, the Patient is not represented by a licensed attorney in a claim a gainst the at-fault party or an insurance carrier, then the Patient hereby grants and conveys to Provider a limited power of attorney to accept any payment provided In Patient's name by any Insurer as consideration for the services provided by Provider to Patient and Patient does grant and convey Provider with a limited power of attorney to sign patient's name to any such insurance check, bank draft or other form of negotiable Instrument remitted by any person or insurer as consideration or compensation for the injuries sustained by Patient and/or the health care services rendered to Patient by Provider.
SECTION 3. If at any time, the Patient is not represented by a licensed attorney in a claim a gainst the at-fault party or an insurance carrier, then the Patient hereby Irrevocably directs all Insurers, Page 1 health care plans, legal counsel, and other persons or parties responsible for the payment, co-payment or other obligation for Patient's health care costs arising from injuries sustained by Patient for which the above referenced services have been provided by Provider, to remit and/or make all monetary payments remitted as consideration, in whole or in part, for those health care services rendered by Provider for and on behalf of Patient, directly to Provider. Patient further directs that any lawyer or representative employed by Patient to represent Patient in any action for which the above referenced services have been rendered by Provider, insurer or third party, shall be, and is hereby, irrevocably Instructed and required to withhold from any monetary distribution to Patient, Patient's lawyer and/or any other person or party asserting any monetary interest against any proceeds to which Patient may awarded, the full amount of Patient's outstanding and unpaid account due and owing to Provider out of any private party settlement proceeds, insurance settlement proceeds of whatever nature (liability, PIP, etc.), and/or any court verdict and remit payment of the dollar amount of Patient's unpaid and outstanding account with Provider, directly to Provider immediately upon receipt of same. This directive made by the Patient to the Patient's lawyer is to be deemed irrevocable and non-rescindable and shall extend to and include any PIP or medical payment benefits recovered by or on the Patient's behalf of the Patient or Patient's lawyer.
SECTION 4. If at any time, the Patient is not represented by a licensed attorney in a claim a gainst the at-fault party or an insurance carrier, then the Patient willfully and voluntarily makes and appoints Provider, through its duly appointed representative, residing in the City of Dallas, Dallas County, Texas, as Patient's lawful Attorney-In-Fact for purposes of receiving and directing disbursement of the above described payments or settlement proceeds to be paid to Patient, or on Patient's behalf, as compensation for those for the health care services rendered by Provider, and the resultant payment obligations owed by Patient to Provider as a result of same. Patient hereby delegates and conveys to Provider those rights and powers of substitution on Patient's behalf, to ask, demand, sue for, collect, endorse, sign, and receive such monetary proceeds, in Patient's name, to PIP insurance, other health benefits, and third party claims relating to services rendered to Patient by Provider. Although Provider is granted such special powers contained herein. Provider is not obligated or compelled to exercise such powers but may do so at Provider's discretion. Patient agrees to cooperate with Provider to request and receive from any insurer, employer, or other third party payer any and all information or supporting documentation concerning or touching upon the handling, calculation, processing, or payment of any claims arising from services rendered to Patient by Provider.
SECTION 5. To the extent that Patient has lawful authority, Patient agrees to toll any applicable statute of limitations that may at any time interfere with Provider's right to collect for services rendered to Patient as well as any other statutory obligation on the part of Provider to bill for or seek collection from any other source of insurance proceeds until such time that Patients claim against the at-fault party or insurance carrier has been resolved through litigation or negotiations . Patient agrees that in the event Patient or Patient's authorized representative, including legal counsel, receives any check, draft, or other payment subject to this Agreement, Patient and Patient's authorized representative shall be deemed to serve in a fiduciary capacity to Provider, for the benefit of Provider, with full obligation to immediately deliver said check(s), draft(s), or payment(s) to Provider. Provider agrees to apply the proceeds from said check(s), draft(s), or payment(s) to Patient's debt for services rendered and to the extent that (a) such services are reasonable and necessary; and (b) charges are reasonable, usual, and customary.
SECTION 6. Patient hereby irrevocable consents to, and authorizes, his lawyer/legal counsel to release to Provider, upon request by Provider, any and all records or documentation pertaining to Provider's insurance claims, legal claims, pending causes of action, or otherwise pertaining to the expense or charge for any service rendered by Provider for Patient's benefit.
SECTION 7. If at any time, the Patient is not represented by a licensed attorney in a claim a gainst the at-fault party or an insurance carrier, then the Patient irrevocably agrees and consents to Provider's submission of a copy of this Agreement and any other claim for payment of insurance proceeds to any and all insurance carrier(s) against whom Patient Is, or may, assert or maintain any claim for damages and reimbursement for the cost for those services provided by Provider, Including, but not limited to, any insurance coverage for Medical Payments, Personal Injury Protection or third party liability insurance payments. A copy of this document shall be as binding as the document bearing original signatures.
SECTION 8. This agreement supersedes and replaces any prior Assignment of Benefits signed between the Provider and the Patient. In the event that any Section or provision of this Agreement is determined to be legally void, Invalid, or unenforceable, all other Sections and provisions of this Agreement shall remain in full force and effect. Patient may not revoke the assignments and agreements contained in this document without the express written consent of Provider.
IN WITNESS WHEREOF, this agreement has been entered Into the day and year set forth below.
