ELECTION TO RECEIVE IN-OFFICE PRESCRIPTION MEDICATIONS, ASSIGNMENT OF BENEFITS, LIENS,DIRECT PAYMENT AUTHORIZATION, AUTHORIZATION TO RELEASE INSURANCE INFORMATION, ANDAUTHORIZATION TO ESCROW UNPAID MEDICAL & PIP BENEFITS
ADCO BILLING SOLUTIONS LP
INSURANCE CARRIER: {insurance}
POLICY NUMBER: {claim}
DATE OF LOSS: {dateOf24}
ELECTION TO RECEIVE IN-OFFICE PRESCRIPTION MEDICATIONS
I understand that my medical provider may prescribe medications for my care and treatment as a result of my condition. I amunder no obligation to receive medications directly from my medical provider for my care and treatment and may elect to haveprescription medications filled by a pharmacy, which may charge a different rate than charged by my medical provider here andcollected by ADCO BILLING SOLUTIONS LP. However, to the extent my medical provider feels my condition needsprescription medications, I am electing to have my medical provider dispense prescription medications in-office.
ASSIGNMENT OF BENEFITS
For and in consideration of ADCO BILLING SOLUTIONS LP on behalf of my medical provider agreeing to pursue theresponsible automobile insurance carrier for payment of benefits due for in-office dispensed prescription medications and notrequiring prepayment for those medications, I hereby irrevocably assign all rights and benefits to ADCO BILLING SOLUTIONSLP for Personal Injury Protection, extended Personal Injury Protection, Medical Payment Coverage, and other benefits which Imay have in accordance with Florida Statute §627.736. This includes any benefits from my insurance company and any otherentity which may be responsible for medical expenses incurred. I further authorize ADCO BILLING SOLUTIONS LP to collectpayments & prosecute any necessary actions to collect payment for in office dispensed prescription medications as they see fitand allowable by law and contract. This assignment of rights and benefits is for in-office dispensed prescription medicationsonly; my medical provider has separate billing for medical services provided. THIS DOCUMENT CONSTITUTES ANASSIGNMENT OF RIGHTS AND BENEFITS.
I hereby further give a lien to ADCO BILLING SOLUTIONS LP against any and all insurance benefits named herein, and anyand all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which Ihave been treated by ADCO BILLING SOLUTIONS LP as a result of the above stated loss date. This document acts as anirrevocable absolute assignment of my rights and benefits to the extent of the charges for prescription medications provided. Iagree to cooperate with ADCO BILLING SOLUTIONS LP and their attorney’s (at their choosing), and to do all things reasonableto effect payment of the bills by the insurance company or other entity to ADCO BILLING SOLUTIONS LP including, but notlimited to, disclosing my medical condition, being available for factual discovery or other cooperation.
This assignment concerns only the bills for in-office prescription medications sought by ADCO BILLING SOLUTIONS LP andthose costs including, but not limited to, attorney’s fees, other costs, and interest necessary in procuring payment from the above-named insurance company and/or other entities. This assignment is not intended to assign any other causes of action that maybelong to the undersigned patient. I agree to pay any applicable deductible or co-payment not covered by any policy of insurancecited above. I understand that as a benefit and convenience to me, ADCO BILLING SOLUTIONS LP will bill and pursuecollection against the insurance company or other responsible entity on my behalf. I hereby instruct and direct my insurancecompany to pay my benefits directly to ADCO BILLING SOLUTIONS LP at the address provided on the bill. If my currentpolicy prohibits direct payment to ADCO BILLING SOLUTIONS LP, then I hereby instruct and direct my insurance companyor other responsible entity to make the check payable to me and mail it to ADCO BILLING SOLUTIONS LP at the address onthe bill. The prescription medications that ADCO BILLING SOLUTIONS LP is billing for is being provided at a reasonable feefor treatment causally related to the above loss date and is medically necessary. I instruct my insurance carrier or other responsibleentity to pay these bills to the full extent of my available benefits under the insurance policy and Florida law. If any portion ofthe charge for these in-office dispensed prescription medications is either reduced or denied in whole or in part, my insurancecompany or other entity is to place funds equal to the amount of the reduced or denied charges into escrow and hold the escrowedfunds until agreement or resolution of legal action by ADCO BILLING SOLUTIONS LP. I further instruct my insurancecompany to make payment for charges submitted by ADCO BILLING SOLUTIONS LP in priority to any other requests to escrowbenefits, including a request by myself to reserve benefits for pending disability claims. I hereby give ADCO BILLINGSOLUTIONS LP limited power of attorney to endorse and sign my name on any draft for payment to either ADCO BILLINGSOLUTIONS LP or myself if said draft represents payment for charges related to prescription medications dispensed by mymedical provider and billed by ADCO BILLING SOLUTIONS LP.
I further direct my insurance carrier or responsible other entity to provide information to ADCO BILLING SOLUTIONS LPwhich is otherwise available to me including but not limited to a copy of any applicable insurance policy, declaration page, allapplicable endorsements, transcripts and/or copies of any recorded statements, examinations under oath and requests for same, independent medical evaluations and requests for same, peer review reports, and a listing of all PIP benefits paid to date whichshall include when claims were made, when the claims were received, the payment or denial of each claim, the amount of thedeductible and the claims applied thereto, and whether benefits have been exhausted and the amount of PIP benefits available,commonly known as a “PIP log”. This request includes the name of other medical providers to whom payments have been undermy policy of insurance. This agreement is intended to serve as an assignment of rights and benefits under my policy of insurancein favor of ADCO BILLING SOLUTIONS LP. If any language within this agreement has the effect of invalidating thisagreement, that language shall be deemed void and the remainder of the assignment shall maintain full force and effect. Aphotocopy of this assignment shall be considered as effective and valid as the original.
If patient is incapacitated or under the age of 18, please indicate the patient name, guardian name and relation to patient,and obtain guardian signature.