GEICO
PERSONAL INJURY PROTECTION BENEFITS
CONDITIONAL ASSIGNMENT OF BENEFITS
Policy Number: Claim Number:
Patient’s Name: Provider’s Name:
I authorize and request Government Employees Insurance Company, GEICO General
Insurance Company, GEICO Indemnity Company, GEICO Casualty Company collectively
referred to as “GEICO”to pay directly to the above-named medical provider, the amount due
to me under the terms of the above-referenced policy as a result of medical care rendered
by that medical provider and all medical staff associated with the provider’s office.
______________________________________ ______________________
Patient’s Signature or Parent/Legal Guardian Date
I have read the information contained in the GEICO informational letter concerning the
Decision Point Review Plan, Decision Point Review and Precertification requirements
(collectively, “Plan”)and, as a condition precedent to GEICO’s acceptance of this assignment,
I agree for myself, and on behalf of all medical staff associated with my office, to the
following:
1. I (We) have fully complied and will comply with all the requirements of the Plan.
2. I (We) have complied and will comply with the terms and conditions of the GEICO
policy.
3. I (We) will initiate all Precertification review and Decision Point Review requests as
required by the Plan.
4. I (We) will submit disputes as defined in the Plan to the Internal Appeals Process set
forth therein. After final determination, I (we) will submit disputes not resolved by the
Internal Dispute Resolution process to the Personal Injury Protection dispute
resolution process set forth in N.J.A.C. 11:3-5.
5. I (We) will submit all disputes not subject to the Internal Appeals Process to the
Personal Injury Protection Alternative Dispute Resolution Process set forth in
N.J.A.C. 11:3-5.
6. I (We) will submit complete and legible medical records with clinically supported
findings to support the diagnosis, causal relationship to the accident, and care plan.
7. I (We) will comply with a request to (i) submit to an examination under oath, and (ii)
provide GEICO with any other pertinent information/documentation that it requests.
8. In the event that I (we) fail to comply with paragraphs one (1) though (7) above, and
such failure results in the imposition of a co-payment penalty, I (we) will hold the
patient harmless for such co-payment penalty insofar as I (we) will not seek payment
from the patient for any unpaid portion of the medical services arising from such co-
payment penalty.
I (we) agree that this assignment is the only valid Assignment of Benefits. I (we) agree that
this Assignment of Benefits may require GEICO’s written consent. I (we) agree that GEICO
has the right to reject, terminate or revoke this Assignment of Benefits.
_______________________________ Date: _____________________________
Provider’s Signature
_______________________________ TIN Number: ______________________
Provider’s Name (Please Print)
Provider’s Address: _____________________________
_____________________________
_____________________________
“Any person who knowingly files a statement of claim containing any false or
misleading information is subject to criminal and civil penalties.” N.J.S. 17:33A-6.
This form is accessible at http://www.geico.com/information/states/nj/.