I _____________________________, hereby assign any and all legal rights required with respect to the enforcement of medical benefit provisions of any insurance policy under which I qualify for benefits, including the right to proceed in AAA arbitration, necessary to collect monies due and owing to the named provider: _____________________________________ for medical services which were provided to me.

This is a limited assignment of rights solely for the purpose of collecting fees for outstanding medical services by the named provider. I specifically do not assign and thereby reserve all other rights and obligations, including the duty to co-operate with the insurance company, with respect to the enforcement of all other medical benefits coverage.

Dated:______________________