ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC.
ASSIGNMENT OF INSURANCE BENEFITS. I hereby authorize payment directly to HCS of insurance benefits for provided services otherwise payable to me. Responsibility for Payment: I agree that I am responsible for the total balance due on my account for all services rendered by HCS even though I may arrange for my healthcare plan to pay for part of it. I agree to allow HCS to use any credit card information that I provide for paying off unpaid balances on my bill. I also agree to pay a charge of $35 dollars for each occurrence of insufficient funds for an attempted check. It is my responsibility to inform HCS of my current address until my balance is paid in full. Co-Payments: Co-payments are due at the time service is rendered unless other arrangements are made. Check, credit or debit cards are accepted. Missed appointments, Late Cancellations, and Other Non-Co-Payment Charges: Because I will reserve appointment times in advance at HCS, I also agree to pay $75 for any scheduled appointments that I miss without advance notice. I understand that advance notice is no less than 2 BUSINESS days. V1.0 Revised 1.2017 Xxxxx Counseling Services Service Agreement Continued If you Choose to Have Your Insurance Pay Directly: It is the policy of HCS to obtain security in the form of your credit card authorization to conveniently pay possible charges that will not be covered by your insurance carrier. These charges can include unanticipated missed appointments/late cancellations, charges for insufficient funds for check or credit card payments, unanticipated deductibles, insurance company payment discrepancies from actual fees, and changes in copayment rate and other changes that insurance plans sometimes make when contracts are renewed. Regular co-payments do not cover these charges. Whenever missed appointments, late cancellations, or insurance non-payments occur, your credit card will be charged the applicable amount and you will be notified. Regular co-payments will be made at each session and you will be able to choose your method of payment at that time.
ASSIGNMENT OF INSURANCE BENEFITS. I agree that physician benefits otherwise payable to the insured are to be made payable to the physicians(s) responsible for my care. Any payment received for this period may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits. Refusal to authorize assignment of benefits will require payment in full by cash, check or credit card at the time of service.
ASSIGNMENT OF INSURANCE BENEFITS. The undersigned authorizes as the Client/Patient or Parent/Legal Representative of Client/Patient, to direct payment to Harmony of any insurance benefits otherwise payable to or on behalf of the Client/Patient for this treatment, including emergency services if rendered, at a rate not to exceed the Harmony’s regular charges. It is agreed that payment to Harmony, pursuant to this authorization by an insurance company shall discharge such company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he or she is financially responsible for charges not covered by the assignment.
ASSIGNMENT OF INSURANCE BENEFITS. I acknowledge that I am responsible for paying ambulance services provided to me by Sunstar, except those eligible under the Membership. I acknowledge that Sunstar will file claims on my behalf with my primary and secondary (if applicable) insurance carrier(s) including Medicare. I herein assign my right to reimbursement for covered transports to Sunstar. INSURANCE PAYMENT OF CLAIMS: I authorize payment resulting from claims billed on my behalf be made directly to Sunstar. In the event I receive payment directly from my insurance company related to the transport, I agree to endorse the check, include explanation of benefits and mail to: Sunstar at P.O. Box 31074, Tampa, FL 33631-3074. If I do not forward the payment to Sunstar, I understand I will receive a bill and be responsible for the payment of this amount. RELEASE OF MEDICAL INFORMATION: As a part of the billing process, I authorize release of any holder of medical information about me or other relevant documentation about me to release to Centers for Medicare and Medicaid Services and its agents and contractors, any and all appropriate third party payers and their respective agents and contracts, as well as Sunstar, any information or documentation in their possession needed to determine these benefits and/or the benefits payable for related service, whether in the past, now or in the future.
ASSIGNMENT OF INSURANCE BENEFITS. I assign and transfer to Austin Neuromuscular Center all rights, title and interest in payments from third party payers, including but not limited to, health plans, health insurers, Personal Injury Protection plans, auto or home owner's insurance. I understand that it is my responsibility to know my insurance benefits and whether or not the services I receive are covered benefit.
ASSIGNMENT OF INSURANCE BENEFITS. I agree that insurance or medical benefits for KFMC’s charges otherwise payable to me are to be made payable to KFMC. Any payment received for services may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits.
ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to Provider. I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles. Authorization to Release Information I hereby authorize Provider to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and(3) allow a photocopy of my signature to be used to process insurance claims I understand that any information disclosed pursuant to this authorization may be disclosed by the recipient pursuant to my providers Notice of Privacy disclosure and may not be protected by the federal privacy regulation. I understand that I have a right to revoke this authorization at any time by providing written notice to my Provider and my health benefit plan (or its administrator) via electronic mail, U.S. mail or facsimile. I further understand that there are no exceptions to my rights to revoke this authorization. Therefore, this authorization will remain in force and effect for claims with date of service within one year of the signature date, or until revoked by me in writing, or until my healthcare claims are adjudicated to my provider’s satisfaction.
ASSIGNMENT OF INSURANCE BENEFITS. I assign to Mercy, my physician or other non-Mercy healthcare professionals involved in my (or the patient’s) care my (or the patient’s) rights under all insurance and benefit plan documents, and authorize direct payment to each healthcare provider of all insurance and plan benefits payments for services provided to me (or the patient) by these providers. By paying my providers directly, my insurance company or employer is fulfilling its obligations to me (or the patient) under the health insurance policy, or the employer is fulfilling its obligations as required by law. I also agree that I (or the patient) am financially responsible for charges not paid according to this assignment.
ASSIGNMENT OF INSURANCE BENEFITS. I agree that insurance or medical benefits for Orthopaedic and Sports Medicine Center charges otherwise payable to me are to be made payable to Orthopaedic and Sports Medicine Center. Any payment received for services may be applied to any unpaid bills for which I am liable, subject to the rules of coordination of benefits.
