ASSIGNMENT OF RIGHTS AND BENEFITS
I, the below named patient/insured, in consideration for being treated by Montesano Spine and Sport without payment in full at the time of treatment (or in advance of treatment), hereby fully and completely assign over to Montesano Spine and Sport any and all MedPay benefits and Personal Injury Protection (PIP) rights and benefits (including but not limited to the right to sue and the right to compromise claims) to which l am entitled by virtue of Florida Statute 627.736 and/or any policy of insurance providing Personal injury Protection benefits and/or MedPay benefits. This assignment also includes and is not limited to the right to reimbursement of transportation costs, my right to bad faith claims and any and all rights I may have to notice of attendance of counsel to, and copies or transcripts or reports of, any EUO (Examination Under Oath), any lME (independent Medical Examination) scheduled or taken by any insurance carrier regarding treatment provided by Montesano Spine and Sport peer review reports, copies of insurance policies, declaration pages and PIP logs.
If any portion of this document is deemed to be inconsistent with an assignment of rights and benefits within the meaning of 627.736, Florida Statutes, or said policy of insurance said portion shall be rewritten in order to conform with Florida law to give full effect to the intended purpose of this agreement, said intended purpose being to create an assignment of rights and benefits from the below named patient/insured to Montesano Spine and Sport.
INFORMED CONSENT TO TREAT: I fully understand that Montesano Spine and Sport is a multidisciplinary organization and that I may be seen by an M.D., P.A., N.P. or a combination of them. I understand that the practice of medicine is not an exact science, and that diagnosis and treatment may involve risks of injury or even death. I also understand that no guarantee or promise has been made as to the results that may be obtained.
LIVING WILL/ADVANCE DIRECTIVE: Montesano Spine and Sport does not honor living wills/advance directives. In the event of a life threating emergency, 911 will be called. If you would like more information, please contact our front desk and they will direct you to the proper person in our organization to speak with.
APPLICANT’S AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS: I hereby authorized in accordance to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-privacy and security requirements that any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, or other organization, institution or person, that has any records or knowledge of me or my health, to release such information to