MEDICAL PROVIDER: TALLAHASSEE PHYSICAL THERAPY & REHABILITATION SERVICES, LLC
For and in consideration of the above-mentioned provider agreeing to pursue my insurance provider for payment of benefits due to me and not requiring repayment for services. I hereby irrevocably assign to the aforementioned medical provider (the "Provider") and Personal Injury protection benefits in accordance with Florida Statue 627.736(5) my insurance company or any other entity that may be responsible for expenses incurred, and I authorize the Provider to prosecute said action and collect legal expenses as they see fit. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF BENEFITS.
I hereby further give lien to the Provider against any and all insurance benefits named herein and any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illnesses for which I have been treated by the Provider. This is to act as an irrevocable assignment of my rights and benefits to the extent of the services provided. I agree to cooperate with the Provider and an attorney that the Provider chooses, and to do all things reasonable to effect payment of the bills by the insurance company to the Provider including, but not limited to, disclosing patient's medical condition and treatment. This assignment concerns only bills for the Provider and those costs (including, but not limited to attorney's fees, court costs, and interest necessary in procuring payment by the above-named insurance company, etc.).
This assignment is not intended to assign any other causes of action that may belong to the undersigned patient. I agree to pay any applicable deductible or co-payment not covered by the PIP insurance coverage. I understand that this is a benefit and convenience to me in that the Provider will pursue collection against the insurance company on my behalf. I hereby instruct and direct my insurance to pay by check, made out and mailed to the Provider at the address listed above. If my current policy prohibits direct payment to doctors, then I hereby instruct the direct you to make checks payable to me and mail it to the Provider. This agreement is intended to serve as an assignment of the patient's benefits under his/her aforementioned insurance policy to the Provider. If any language within the agreement has the effect of invalidating this assignment, that language shall be deemed void and the assignment shall remain in full force and effect. A photocopy of this assignment shall be considered as effective and valid as the original.
Patient further agrees that should the invoices for services rendered fail to be paid by the insurance provider or the patient and said invoice for services is referred to any attorney for collection the Patient shall be responsible for the attorney fees and court costs.