I hereby authorize Progressive Physical Therapy Center, LLC to furnish my attorney or insurance company with copies of my medical records. This applies to requests in reference to all illnesses and injuries sustained by my dependents or myself; including, but not limited to, the injuries that were sustained in this injury which occurred on or about I irrevocably assign, authorize, and direct said attorney or insurance company to pay Progressive Physical Therapy Center, LLC for all services rendered. Payment may come from the proceeds of any recovery in my claim or case, whether said proceeds are recovered because of compromise, collection of judgment, or monies received from PIP, MedPay, no-fault, or other insurance policies. Services include, but are not limited to, reports, conferences, preparation for testimony, depositions, and court testimony as an expert witness. I understand that fees are available upon request.
I also understand that reimbursement for services may be less than that charged, due to agreements with managed care organizations but that these payments will represent only partial payment for services and that I am fully responsible for the remainder of all fees. I understand that payment for services is not contingent upon recovery and that this does not relieve me of my personal, primary responsibility to pay for the services rendered. Furthermore, I agree to pay costs incurred in the collection of these charges, including reasonable attorney's fees. I hereby agree to waive the defense of the statute of limitations as it pertains to any claim filed against me beyond three years (or other statutory period) after services are rendered.
I agree to all the above terms and further authorize my attorney to comply with these terms. I have completely read this agreement, I understand it fully, and I have had ample time to ask questions.
Please sign your name in the area below
I, the undersigned attorney or Law Firm hereby agree to:
1. Agree with and will comply fully with this Authorization and Assignment.
2. Withhold and pay from settlement proceeds, collection or judgment, PIP, MedPay, or other insurance proceeds, in the full amount or in an agreed reduced amount of physical therapy charges after contacting the providers office for a current balance.
3. Advise Progressive Physical Therapy Center, LLC on the status of the above referenced claim within ten days of the request.
4. Notify Progressive Physical Therapy Center, LLC in writing immediately of any change in the status of the claim that may preclude payment of charges and including the withdrawal of legal representation.
5. Require any attorney to whom the undersigned refers this case, within or outside the firm, to honor this assignment as a condition of referral.
6. Furnish home and work address, insurance information and pertinent accident reports about the patient/client or family to aid in the collection of the medical bills.
Confidentiality Notice
This facsimile contains confidential information, which may also be legally privileged, and which is intended only for the use of the addressee(s) named above. If you are not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination or copying of this facsimile, or the taking of any action in reliance on the contents of this telecopied information, may be strictly prohibited. If you have received this facsimile in error, please notify us immediately by telephone and return the entire facsimile to us at the above address via the U.S. Postal Service.