Assignment of Benefits, Rights & Appeal Authorization

Appointment of Representative

The undersigned herby appoints Evo Advanced Foot Surgery and Evo Advanced Foot Surgery or its assignee, as my duly authorized representative and assignee during any; (1) Administrative claims process: (2) Appeal or Review process for denied claim: or (3) State of Federal legal process, necessary to collect claims submitted on my behalf for health insurance benefits, but denied on my plan.

The CLAIMS ADMINISTRATOR, PLAN ADMINISTRATOR, or GROUP INSURANCE ADMINISTRATOR for my medical insurance plan are all hereby notified and directed by me to henceforth regarding any and all communications, particularly including all request for information, received from my representative during the administrative process, as though these communications had been received from me.

  • I understand that the United States Department of Labor has published the national minimum standards for the administrative process and review of claims, found at 29 CFR 2560.503-1.

  • I ask all administrators to abide by these minimum standards.

  • I demand complete and timely disclosure to my representative of (a) All pertinent documents, including the identity of their signatory or author, and (b) The identity of any person or entity processing the discretion to approve or deny may claim.

  • I demand compliance with applicable California enactments regarding full and fair review of claims.

Business Purpose and Right to Receive Benefits

The duly authorized representative and assignee named above in (1) is authorized to directly receive payment for the medical benefits due to me under my insurance plans.  This assignment of benefits by me is complete.  I retain no interest in the benefits due to me under these claims for medical care and facility fees.  This assignment is given by me in return for the medical care and related for payment of all charges incurred.

Additionally, regardless of my insurance benefits, if any, I understand I am financially responsible for the fees for the services rendered.  I understand that my assignment of these rights and my appointment of an administrative representative serve as a valid business purpose.  That purpose is to provide an effective mechanism for my doctors and other healthcare to deal with any administrative or legal process that may be necessary to collect the benefits due for the services provided.

The medical and business purpose for the assignments created under federal law in MISIC v BUILDING SERVICE HEALTH 789 F2D 1374 (9TH CIR. 1986).  In furtherance of this business purpose, my assignee is not necessarily my healthcare provider for any specific claim, but is rather the individual(s), organization, group and/or corporation designated by my providers to deal with all administrative and legal matters.

Judicial Review

If my claim for benefits is administratively denied in whole or in part, I hereby assign ALL causes of action for judicial review to the individual(s), organization, group, and/or corporation designated in (1) My assignee may “Stand in my shoes”, as that phrase is understood under assignment by law.

I intend my personal standing under the ERISA civil enforcement procedure (codified at 29 u.s.c 1132) to be transferred to my assignee, so that he, she, they, or it may seek judicial review of benefits claim denials, under 1132 (a) (1) (B).  My assignment also includes my right to seek my review as claimant, under 1132 (C), of any administrators’ refusal or failure to provide information, 30 days after written request.

Member Authorization for a Designated Representative to Appeal Adverse Determination

I hereby authorize Evo Advanced Foot Surgery to appeal my insurance carrier’s determination concerning any denials of claims or incorrect payment of claims (including delayed payment of claims), on my behalf, as my Designated Representative, and, as part of the appeal, I hereby authorize my insurance carrier in its decision letter and in connection with the processing of my appeal, to communicate with my Designated Representative in all aspects of the appeal. I understand that these communications may contain the following: 

All medical and financial information contained in my insurance file, including but not limited to  treatment for venereal disease, alcoholism and drug abuse, abortion, mental disorder and HIV status relating to my examination, treatment and hospital confinement in connection with the determination which is being appealed. 

I understand this information is privileged and confidential and will only be released as specified in this Authorization, or as required or permitted by law. 

By signing this form I am permitting Evo Advanced Foot Surgery to submit claims, appeals and all necessary correspondence to my insurance company.  This signed document supersedes any forms required to be signed by me to release claim or treatment related information.