By signing this agreement Sample Clauses

By signing this agreement. I hereby assign all applicable health insurance benefits and all rights and obligations that I and my dependents have under my health plan to the Centric health and Centric Health’s representatives (hereinafter, “My Authorized Representatives”) and I appoint them as my authorized representative with the power to : o File medical claims with the health plan o File appeals and grievances with the health plan o Discuss or divulge any of my personal health information or that of my dependents with any third pary including the health plan. • I certify that the health insurance information that I provided to Centric Health is accurate as of the date set forth below and that I am responsible for keeping it updated. • I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Centric Health 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. • I hereby authorize My Authorized Representatives 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 this agreement will remain in effect until I have formally revoked in writing. • I understand Centric Health’s financial policy may be amended without prior notice. • I acknowledge I have read and understand Centric Health’s Financial Policy. A copy will be provided to me upon request. Patient Name: