ASSIGNMENT OF RIGHTS AND BENEFITS WITIDN THE MEANING OF 627.736, FLORIDA STATUTES: I, the below named patient/insured, in consideration for being treated by Surgery Consultants of Florida without payment in full at the time of treatment (or in advance of treatment), hereby fully and completely assign over to Surgery Consultants of Florida 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 I 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 IME (Independent Medical Examination) scheduled or taken by any insurance carrier regarding treatment provided by Surgery
Consultants of Florida, peer review reports, copies of insurance policies, declaration pages and PIP logs. As additional consideration I also agree as follows:
- A. I agree and stipulate that venue for any litigation involving the payment of any benefits under any policy which may cover me shall be in Sarasota County, Florida.
- B. I agree and stipulate that should my attorney or representative request a reduction of any costs or fees payable by me personally that my attorney or representative must provide to Surgery Consultants of Florida the terms of the settlement or recovery obtained by me as well as an accurate and complete copy of the actual settlement statement and disbursement statement for my case.
- C. I grant to Surgery Consultants of Florida, full power and authority to endorse and sign checks or drafts for payment of bills submitted by Surgery Consultants of Florida, for services rendered to me by them.
- D. I authorize and direct my present or future attorneys and my Personal Injury Protection insurance carrier or carriers to release any and all medical and legal information in their possession about me to Surgery Consultants of Florida immediately upon demand.
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 I insured to Surgery Consultants of Florida
INFORMED CONSENT TO TREAT: I fully understand that Surgery Consultants of Florida is a multidisciplinary organization and that I may be seen by an M.D., D.O., D.C., P.A., N.P., L.M.T. 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 result that may be obtained.
LIVING WILL I ADVANCE DIRECTIVE: Surgery Consultants does not honor living wills I advance directives. In the event of a life threatening 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 authorize in accordance to the Health Insurance Portability and Accountability Act of1996 (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 Surgery Consultants of Florida I also give my permission for Surgery Consultants of Florida to RELEASE ANY of my records to a medical provider or facility, or to my attorney requesting such information FROM Surgery Consultants of Florida and to any insurance company responsible for payment. This release specifically includes but is not limited to authorization to release any and all medical records and information associated with (or in reference to) the following conditions: Positive exposure to HIV infection, ARC, AIDS, alcohol or drug dependency, mental and nervous disorders. A photographic copy of this authorization shall be valid as the original. This authorization shall be valid for five years from the date of signature. I give permission to my current attorney or any attorney in the future representing me to access my medical records electronically.
GUARANTEE OF PAYMENT: I agree to be fully responsible for all costs and services provided to me, including transportation charges. I understand that I am responsible for any costs incurred in the collection of my account (s) in case of default, including reasonable attorney's fees and costs. I also grant Surgery Consultants of Florida a lien against any recovery that I may have now or in the future against any tortfeasor or any responsible insurance carrier. I also agree that if!, my attorney or representative request a narrative report regarding my condition that the cost of such report shall be my responsibility because such a report is not compensable under PIP coverage. I promise to sign a letter of protection in favor of Surgery Consultants of Florida and hereby direct that any attorney representing me now or in the future to execute that certain letter of protection in favor of Surgery Consultants of Florida that has been previously executed by me.
STATEMENT OF TRUTHFULNESS: I state that any and all of the information provided to Surgery Consultants of Florida concerning my financial information, insurance information, accident and automobile information, and any information concerning coverage under any type of health care plan is true and correct. I further understand and acknowledge that if any of the information I provide Surgery Consultants of Florida is in any way incorrect or untrue, then I may be liable for damages and penalties for violating this agreement and Florida law, including but not limited to Florida Statute 817.50 which prohibits a person from fraudulently obtaining services from a medical facility.
The undersigned has read this entire document, agrees to its terms and conditions and authorizes it and the underlying
signature may be electronically copied, stored and reproduced and any such copied, stored or reproduced version be used as