Circular Exhibit 06-02-B
For a copy of the IHS - 949 (4/06) THIRD PARTY REPORT, please contact your Area Directives, Delegations and Control Officer or the Management Policy and Internal Control Staff at 301-443-2650
For a copy of the IHS-960 (4/06) - NOTICE TO PATIENT, please contact your Area Directives, Delegations and Control Officer or the Management Policy and Internal Control Staff at 301-443-2650
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
INDIAN HEALTH SERVICE
AGREEMENT TO ASSIGN CLAIM UPON REQUEST
PUBLIC LAW 87-693, (42 U S.C. §§ 2651-2653)
In accordance with the provisions of Public Law 87-693 (42 U.S.C. §§ 2651-2653), I hereby agree to assign to the United States of America, upon request, any claim, demand, entitlement, or cause of action which I now have or which I may hereafter have against a third person for the reasonable value of hospital, medical, surgical, or dental care and treatment (including prostheses and medical appliances) furnished or to be furnished to me by o r at the expense of the United States as the result of an injury or disease suffered by me on or about _________________________ under circumstances creating a tort liability upon such third person to pay damages to me.
It is understood and agreed that I may assert a personal injury claim in my own behalf against such third person, and may include as a part thereof the reasonable value of the hospital and medical care and treatment furnished to me by or at the expense of the Unites States. If I assert a personal injury claim in my own behalf and make a recovery therein, whether by judgment, compromise settlement, or otherwise, I agree to hold in trust for the United States out of the proceeds thereof the full amount of its claim for the reasonable value of the medical care and treatment furnished to me by or at the expense of the United States and to pay over such amount as directed by the United States.
THIS AGREEMENT IS NOT AN ASSIGNMENT AND DOES NOT CONSTITUTE A TRANSFER OF ANY PRESENT INTEREST IN ANY CLAIM OR CAUSE OF ACTION WHICH I NOW HAVE OR MAY HEREAFTER HAVE AGAINST A THIRD PERSON.
Any assignment demanded by the United States in accordance with the above cited statute shall be in writing, and the cause of action thereby assigned shall not vest in the United States unless and until the assignment is accepted in writing by the department or agency concerned, or by the Attorney General of the United States.
DATED this ___________________ day of _______________________, ____________________
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