Assignment of Benefits

I hereby authorize payment directly to the above named doctors as a practice or individually of any insurance benefits otherwise payable to me for services provided to me.

In the event that the doctors individually or on behalf of their practice elect to bring a lawsuit or petition for arbitration against the insurance carrier, I assign my rights, interest under the medical expense benefits and/or PIP section of any insurance policy under which I am entitled to proceed for benefits. This assignment shall allow an attorney of their choosing to bring suit or submit to arbitration their claim for any unpaid bills for treatment rendered for injuries I sustained in this or any accident. I agree to fully cooperate with them in the collection of the medical expense benefits/personal injury protection claim from the insurance carrier, including full cooperation with the attorney chosen by the assignee.

In the event this assignment is held invalid for any reason, I hereby authorize the physicians or their practice to appoint an attorney of its choice to represent me directly against an insurer from which I may collect PIP benefits and to bring a claim in a forum of his/his choice. This appointment is not intended to conflict with any other attorney who currently represents me.

I further authorize the assignors to release any and all information concerning my injury or illness and its treatment to the attorney designated by the assignee or third persons who are involved in the action to collect benefits. A photocopy of this authorization shall be deemed valid as original.