Assignment of Benefits

to any insurance company with coverage applicable to my claims) and to any attorney representing me assignment of benefits in consideration of oak hollow chiropractic's willingness to treat me on credit without demand for payment at the time services are rendered, i hereby agree and stipulate as follows i irrevocably assign to oak hollow chiropractic any proceeds or compensation that i am or may become entitled to receive as a result of injuries that occurred on to the extent of the chiropractic services rendered i make this agreement without prejudice to any tights i may have to prosecute legal claims against any party who may be liable for my injuries, but i hereby authorize and instruct you to pay directly to oak hollow chiropractic, from any disability benefits, medical payments benefits, liability benefits, health and accident benefits, workers compensation benefits, judgments, settlements, or proceeds of any kind that would otherwise be payable to me, such sums as are due or may become due to oak hollow chiropractic for its services rendered i appoint oak hollow chiropractic as my attorney in fact to affix my name as an endorsement upon the reverse of any check or draft upon which i am a named payee and to deposit said check or draft and apply the proceeds to any unpaid balance i may have with oak hollow chiropractic i authorize oak hollow chiropractic to release to any insurer with applicable coverage or to my attorney or successor attorney any information regarding my injuries, prior medical history, or treatment as may be necessary to facilitate collection of proceeds under this assignment i acknowledge that i remain personally liable for the total amount due to oak hollow chiropractic for services rendered, including any balance remaining after the application of insurance payments and settlement or judgment proceeds if oak hollow chiropractic is required to take legal action against me to recover any unpaid balance on my account, i agree to reimburse oak hollow chiropractic for its costs of recovery, including reasonable attorney's fees print name (patient) patient signature date witness pursuant to n c g s 44 49 and 44 50, oak hollow chiropractic hereby asserts and gives notice of a lien upon any sums recovered in damages for personal injury in any civil action and also upon all funds paid to the above named patient in compensation for or settlement of injuries sustained, whether in litigation or otherwise oak hollow chiropractic hereby requests that if its claim is not paid in full from the foregoing proceeds, a full disclosure and accounting of proceeds be provided inconformity with n c g s 44 50 i oak hollow chiropractic agrees to be bound by any confidentiality agreements regarding the contents of the accounting oak hollow chiropractic by