ASSIGNMENT OF BENEFITS

I, hereby authorize and direct any insurance company with whom I may make a claim for PIP, Med-Pay, or Med-Expense benefits, and/or my attorney, to pay directly to Progressive Physical Therapy Center any money that is owed to Progressive Physical Therapy Center for services provided to me. 

In the event, any insurance company is obligated to reimburse me for charges. I incur with Progressive Physical Therapy Center refuses to make such payments after demand is made by either me or Progressive Physical Therapy Center, I hereby assign and transfer to Progressive Physical Therapy Center any and all causes of action that I have against said insurance company, including but not limited to the right to bring a lawsuit for the failure to pay the available PIP, Med-Pay, or Med-Expense benefits up to the amount of Progressive Physical Therapy Center’s full bill. 

I authorize Progressive Physical Therapy Center to bring any such cause of action either in my name or in Progressive Physical Therapy Center's name. I further authorize Progressive Physical Therapy Center to compromise, settle, or otherwise resolve any such claim arising out of the insurance company's failure to pay to Progressive Physical Therapy Center the full limit of available PIP, Med-Pay, or Med-Expense benefits up to the amount of its full bill. 

I understand that I remain personally responsible for the total amounts due to Progressive Physical Therapy Center for services rendered. I understand that payment is due at the time services are rendered, and that the Progressive Physical Therapy Center may provide to me the option to have the bill paid through my health insurance or third-party payer sources. I agree that this document does not constitute any consideration for Progressive Physical Therapy Center to await payment, and that payment may be demanded from me immediately upon the rendering of services. 

I authorize Progressive Physical Therapy Center to release any information pertinent to my case to any insurance company or attorney to facilitate the collection of my bill. I agree that Progressive Physical Therapy Center be given Power of Attorney to endorse or sign my name on any and all checks for payment of my health provider bill. All Progressive Physical Therapy Center rights herein are assignable by Progressive Physical Therapy Center.