Assigment To Chair WCB Of Cause Of Action Against Health Care Provider
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Assigment To Chair WCB Of Cause Of Action Against Health Care Provider Form. This is a New York form and can be use in Workers Compensation.
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Tags: Assigment To Chair WCB Of Cause Of Action Against Health Care Provider, C-370, New York Workers Compensation,
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)
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