SATISH NARAYAN, MD & NISHA SATISH, MD
7170 Preston Rd. Ste 200• Plano, TX 75024 4501 Joe Ramsey Blvd Ste 260 • Greenville, TX 75401
Tel (972) 232-7474 • Fax (972) 232-7401 Tel (903) 455-4300 • Fax (903) 455-4301
Psymed Solutions
ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND
ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND/ OR HEALTH BENEFIT
PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED
REPRESENTATIVE
Satish Narayan, MD Nisha Satish, MD Humaira Khalid, MD Vivian Kisanga, NP Dominique Wilson, NP
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Primary Medicare Supplement/Secondary
Carrier Name: _____ _________________ Carrier Name: __________________________________
ID#: ______________________________________ ID#: _________________________________________
Group Name / Number: _______________________ Group Name / Number: _________________________
Policy #: ___________________________________ Policy #: _____________________________________
Ins. Co. Phone #: (____)_______________________ Ins. Co. Phone #: (____)_________________________
Insured Party Information (If other than Patient): Insured Party Information (If other than Patient):
Name: _____________________________________ Name: _______________________________________
Date of Birth: _______/_______/______ Date of Birth: _______/_______/______
Address: ___________________________________ Address: _____________________________________
SS#:______-______-______ SS#:______-______-______
Insured’s Employer: __________________________ Insured’s Employer: ____________________________
Relationship to patient: ________________________ Relationship to patient: __________________________
I hereby assign and convey directly to the above- named health care provide, as my designated authorized representative, all medical benefits
and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies and/or medications rendered or provided by
the above- named healthcare provider, regardless of its managed care network participation status. I understand that I am financially responsible
for all charges regardless of any applicable insurance or benefits payments. I hereby authorize the above-named healthcare provider to release all
medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to
release to the above-named healthcare provider any and all plan documents, summary benefit description, insurance policy, and/or settlement
information upon written request from the above-named health care provider or its attorneys to order to claim such medical benefits.
In addition to this assignment of medical benefit and/or insurance reimbursement above, I also assign and/or convey to the above-named
healthcare provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health
insurance, or tortfeasor insurance concerning medical expenses incurred as a result of medical services, treatments, therapies and/or medications I
receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This
constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims other legal and/or administrative claims.
I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place
a lien on) the medical benefits related to the services, treatments, therapies and/or medications provided by the above-named health care provider,
including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of
fiduciary duty claims) .The assignee and/or designated representative (above-named provider) is given the right by me to (1) obtain information
regarding the claim to the same extent as me; (2) submit evidence; (3) makes statements about facts or law; (4) make any request including
providing or receiving notice of appeal proceedings (5) participate in any administrative and judicial actions and pursue claims or chose in action
or right against any liable party, insurance company, employee benefit plan, health care benefit plan or plan administrator. The above-named
provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit
plan, plan administrator or insurance company in my name with derivative standing at provider’s expense.
Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA,
Medicare and applicable federal and state laws. A photocopy of this assignment is considered valid, the same as if it was the original.
I HAVE READ AND FULLY UNDERSTAND THE AGREEMENT.
___________________________________________________ _________________________________
Patient signature (Parent /Guardian’s signature if patient is under 18) Date
___________________________________________________ _________________________________
Patient Name (please print) Relationship to patient
___________________________________________________ _________________________________
Witness Date