Assignment and Designation of Authorized Representative

The Assignment form is a crucial document that you must obtain in order to serve as the authorized representative of the patient to pursue the patient’s rights under ERISA. In other words, ERISA is a right belonging to the patient – not the doctor – unless the doctor obtains an Assignment. Use the Form and article below for more information:

This form is not intended as, or a substitute for, legal advice. The ICS does not and cannot provide legal advice and recommends that providers seek legal counsel for review of this and all forms used in practice. This form has been developed in recognition of the fact that there is no standard form prescribed by all courts in interpreting various state and federal laws. This form has been designed to operate as broadly as possible and to provide the broadest possible protection of the health care provider’s right to fair reimbursement. However, no court has ruled on the validity of this particular form, nor does the ICS guarantee that use of this form will result in payment to the provider.