Fillable DISCLOSURE REQUIREMENTS (hereinafter Conditional Assignment) CONDITIONAL ASSIGNMENT OF

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DISCLOSURE REQUIREMENTS (hereinafter Conditional Assignment) CONDITIONAL ASSIGNMENT OF

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New Jersey Property-Liability Insurance Guaranty Association
New Jersey Surplus Lines Insurance Guaranty Fund
Unsatisfied Claim and Judgment Fund
Workers’ Compensation Security Fund
233 Mount Airy Road
Basking Ridge, New Jersey 07920
Tel: (908) 382-7100
www.njguaranty.org
CONDITIONAL ASSIGNMENT OF PERSONAL INJURY PROTECTION BENEFITS &
DISCLOSURE REQUIREMENTS (hereinafter “Conditional Assignment”)
Claimant: __________________ Date of Accident: _______________ Claim Number: _______________
PLEASE READ CAREFULLY AS THIS ASSIGNMENT IMPOSES DUTIES AND OBLIGATIONS UPON
THE PERSON(S) AND/OR THE ENTITIES WHO SIGN IT
Under your personal injury protection (“PIP”) coverage, the New Jersey Property-Liability Insurance Guaranty Association
(“NJPLIGA”) can reimburse you directly for covered expenses. However, if you are being presented with this form, your doctor or
other health care provider is asking that your benefits be "assigned" to them so that NJPLIGA may instead pay your provider directly.
If you choose to assign your benefits to your doctor or other health care provider, you no longer have the right to file any claim,
lawsuit or arbitration against NJPLIGA seeking reimbursement for those benefits. Nothing in this Conditional Assignment authorizes
the doctor or other health care provider and/or its agents to pursue a claim for bodily injuries on a patient or claimant’s behalf.
BY CLAIMANT: By signing this Conditional Assignment below, I _________________________________________________,
(Please Print - Name of Claimant/Patient)
hereby assign my right to pursue a claim for reimbursement of PIP benefits under the applicable insurance policy or pursuant to the
Unsatisfied Claim and Judgment Fund (“UCJF”), N.J.S.A. 39:6-60 et seq., to the doctor or other health care provider (his/her
employees, designees, and/or assignees) that has executed this Assignment. This Assignment is expressly contingent upon the doctor
or other health care provider agreeing to the terms set forth herein. I acknowledge that the doctor or other health care provider’s failure
to honor the obligations set forth below may render this Conditional Assignment null and void. Furthermore, I authorize the release of
medical records to NJPLIGA. A photocopy of this document shall be considered as effective and valid as the original.
BY PROVIDER: By signing this Conditional Assignment below, I _________________________________________, on behalf of:
(Please Print – Name of Provider/Authorized Representative)
_______________________________________________________________________________________________________,
(Please Print – Name of Provider)
assert that I am a representative of the health care provider noted above with the authority to bind the provider to the terms as set forth
in this Assignment. I have read the information contained in NJPLIGA’s Decision Point Review Plan (“DPR Plan”), NJPLIGA’s
information letter concerning its DPR Plan and this Assignment. As a condition precedent to NJPLIGA’s accepting this assignment of
benefits, on behalf of the doctor or other health care provider noted above individually, and on behalf of all medical staff associated
with the provider, we collectively understand and agree to abide by the following:
1. To obtain a fully executed Conditional Assignment in order to be paid directly by NJPLIGA for covered services. NJPLIGA’s
CONDITIONAL ASSIGNMENT OF PERSONAL INJURY PROTECTION BENEFITS & DISCLOSURE REQUIREMENTS
form is the only valid assignment of benefits. A fully executed copy of this Conditional Assignment must be furnished to
NJPLIGA upon request.
2. That the Conditional Assignment must be signed by the claimant and the treating health care provider or an agent authorized to
act on behalf of the provider. By executing the Conditional Assignment, or having it executed, the treating health care provider
agrees to be bound by the terms of the Assignment and other applicable terms, conditions and duties as set forth in all applicable
statutes, rules, regulations and NJPLIGA’s DPR Plan. The treating health care provider agrees that NJPLIGA has the right to
reject, terminate or revoke the Conditional Assignment at any time.
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3. Consistent with N.J.S.A. 39:6A-13(b), N.J.S.A. 17:33A-1 et seq., or other applicable law, the treating health care provider agrees
to the production and inspection of documents, objects and facilities reasonably relevant to or having nexus to the claim being
presented. This includes but is not limited to:
a. Allowing and providing NJPLIGA or its agent(s) with the authority to inspect original documents and credentialing
reasonably relevant to or having nexus to the claim being presented that are in the possession of the treating health care
provider, its agent(s), or which can be obtained by the treating healthcare provider or its agent(s) using reasonable
efforts.
i. Inspections will be made during mutually convenient times but within thirty (30) days of any such request;
ii. Upon mutual agreement, the inspection of documents may be waived by NJPLIGA if copies are provided
within thirty (30) days of any such request and the copies are determined to be suitable by NJPLIGA for the
purposes of its investigation.
b. Allowing NJPLIGA or its agent(s) to verify by inspection of the premise(s), or other location(s) where any professional
services and/or treatment or therapy were rendered that the equipment in such premise(s) or location(s) matches the
services billed. Such inspections will be conducted at a mutually convenient time and date within thirty (30) days of any
such request.
4. To cooperate with any investigation conducted by NJPLIGA including, but not limited to, providing interviews, written or
recorded statements and examinations under oath on any subjects reasonably related to or having nexus to the claim being
presented in accordance with NJPLIGA’s DPR Plan.
5. That Decision Point Review/Precertification by NJPLIGA or its agent(s) is only a determination of medical necessity and is not a
guaranty of payment. Decision Point Review/Precertification does not confirm or verify eligibility for coverage, statutory benefits
or payment. Decision Point Review and Precertification by NJPLIGA or its agent(s) shall not be used in litigation in any forum,
venue or court proceeding to imply, infer or indicate that payment should be made except as to an issue of medical necessity.
6. To hold harmless the claimant and NJPLIGA or its agent(s) for any reduction of benefits caused by the provider’s failure to fully
comply with the terms and conditions of the DPR Plan.
7. To irrevocably agree to follow NJPLIGA’s or its agent(s) internal appeals processes and to exhaust such processes prior to
submitting any unresolved disputes through the New Jersey PIP dispute resolution system pursuant to N.J.S.A. 39:6A-1 et seq.
I HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS
ASSIGNMENT AND NJPLIGA’s DPR PLAN. I UNDERSTAND THAT I AM BOUND BY THESE TERMS, AS IS THE
PROVIDER, PRACTICE OR FACILITY WHERE THE PROFESSIONAL SERVICES AND/OR TREATMENT IS/WAS
PROVIDED. THE PROVIDER IS ALSO BOUND IF HE/SHE HAS AUTHORIZED SOMEONE TO SIGN THIS
ASSIGNMENT ON HIS/HER BEHALF.
Signature: _________________________________________________________________ Date:________________________
(Claimant/Patient)
Signature: _________________________________________________________________ Date:________________________
(Provider/Authorized Representative)
“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.A. 17:33A-6
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DISCLOSURE REQUIREMENTS (hereinafter Conditional Assignment) CONDITIONAL ASSIGNMENT OF

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Completed 12 January 2022

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