(DR.

OFFICE)
RE-ASSIGNMENT OF BENEFITS/POLICY RIGHTS

PATIENT:

The undersigned Provider’s Representative for (DRS OFFICE), hereby re-assigns the
benefits of insurance under the health insurance or other insurance with (INSURANCE
COMPANY) or any other collateral source for services rendered to the undersigned
patient ______________ and covered under health insurance coverage under
(INSURANCE COMPANY) Policy Number __________ for injuries sustained and
treatment rendered from an automobile accident the patient ___________ was involved
in that occurred on Month Day, 20__.

This re-assignment includes but is not limited to the transfer to the patient, ___________,
of all benefits and rights under the policy including the right to collect benefits directly
from patient’s insurance company for services rendered by (DRS OFFICE) to the above-
referenced patient, ______________ and all rights to proceed against the
patient,____________________, insurance company, (INSURANCE COMPANY), in
any action including legal suit.

Patient, ________________ accepts and agrees that (DRS OFFICE) has re-assigned all
of the benefits and rights to patient ________________ under the above- referenced
policy of insurance and (DRS OFFICE) agrees to same.

This re-assignment of benefits and policy rights has been reviewed by the undersigned
parties, entered into voluntarily and of the free will of both parties to this re-assignment.

_______________________________________ ____________________
Patient’s Signature Date

______________________________________ ___________________
Provider’s Representative Date
(DRS OFFICE)