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Assigment To Chair WCB Of Cause Of Action Against Health Care Provider C-370 - New York
| Assigment To Chair WCB Of Cause Of Action Against Health Care Provider Form. This is a New York form and can be used in Workers Compensation . |
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ASSIGNMENT TO CHAIR, WORKERS' COMPENSATION BOARD OF CAUSE OF ACTION AGAINST HEALTH CARE PROVIDER FOR RECOVERY OF MONEY PAID FOR TREATMENT UNDER THE WORKERS' COMPENSATION LAW WCB Case Number: ______________________ I, ______________________________________________, do hereby assign to the Chair of the New York State Workers' Compensation Board ("Chair"), 20 Park Street, Albany, NY 12207, the Chair's successors and designees, the cause of action I have against _______________________________________, in the amount of $______________________ for the recovery of fees for medical care and treatment rendered in relation to an injury which is the subject of the above indicated claim. That amount was paid by me to __________________________________, and has not been returned as required by Section 13-f(1) of the Workers' Compensation Law. I hereby empower the Chair, the Chair's successors and designees to take any and all legal measures which are proper and necessary to achieve recovery of said amount. Whether to compromise the cause of action hereby assigned shall be at the sole discretion of the Chair, the Chair's successors or designees. Whether to commence an action pursuant to this assignment shall be at the sole discretion of the Chair, the Chair's successors or designees. Any costs or fees associated with such action shall be the sole responsibility of the Workers' Compensation Board ("Board"), but may be recouped by the Board from any recovery obtained. Any recovery obtained pursuant to this assignment in excess of the costs and fees incurred by the Board shall be in trust to me. _______________________________________________ Claimant's Signature ________________ Date In the presence of: State of New York) ) ss: County of ) On the __________________________ day of _____________________, 20____, before me came ___________________________________________________________, known to be the individual described herein and who executed the foregoing instrument and acknowledged the (s)he executed same. ________________________________________________________ Notary Public C-370 (9-06) American LegalNet, Inc. www.FormsWorkflow.com
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