Assignments of Benefits

Last Updated: March 10, 2023

Assignment of Benefits; Appointment as Legal Authorized Representative

I assign all applicable health insurance benefits and all rights and obligations that I and my dependents have under my health plan to Tiero LLC, its providers and its staff (“My Authorized Representatives”) and I appoint them as my authorized representative with the power to: file claims, appeals, and grievances with my health plan; discuss/divulge any of my personal health information (“PHI”) or that of my dependents with any third party including my health plan; institute litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions; obtain copies of Plan Documents and Summary Plan Documents; and file appeals with employers after appeals are exhausted. I specifically authorize submission of PHI to my employer and my health insurer and health administrator for the purpose of getting my medical claims properly paid.

Authorization to Release Information

I authorize My Authorized Representatives to: (A) release any information necessary to my health plan (or its administrator) regarding services rendered; (B) process insurance claims generated in the course of services being rendered; and (C) provide signature on my behalf to be used to process insurance claims for the period lifetime. This order will remain effective until revoked in writing.


I designate, authorize, and convey to My Authorized Representatives to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plain (1) the right and ability to act as My Authorized Representatives in connection with any claim, right or cause of action including litigation against my health plan (even to name me as plaintiff in such action) that I may have under such insurance policy and/or benefit plan and (2) the right and ability to act as My Authorized Representatives to pursue such claim, right or cause of action in connection with said insurance policy and/or benefit plan governed by the provisions ERISA with respect to any healthcare expense incurred as a result of the services I received from Tiero LLC, its providers and its staff and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. This constitutes an express and knowing assignment of ERISA breach and/or fiduciary duty claims and other legal and/or administrative claims. I authorize communication with My Authorized Representatives. I understand I can revoke this authorization in writing at any time.