You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. This agreement will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as the original.
Medicare Patients
I request that payment of authorized Medicare benefits be made to me or on my behalf to Desert Valley Chiropractic for any services furnished by Drs. Katherine and David Iacuone. I authorize that any holder of medical records about me to release to the Health Care Financing Administration and its agents any information necessary to determine benefits and process the insurance claim.
Non-Medicare Patients
In consideration of services to be rendered, I hereby assign and transfer to Desert Valley Chiropractic any benefits payable to or for my benefit under hospitalization, sickness or accident insurance, and any other insurance coverage, to include major medical or P.I.P., Medpay for the payment of such services rendered. I agree to cooperate, aid and assist Desert Valley Chiropractic in procuring all possible insurance benefits including initiation and fulfillment of all policy provisions such insurance companies may require for payment.
I further assign and transfer to Desert Valley Chiropractic an interest in any cause of action I may have arising out of injuries directly or indirectly resulting in this period of treatment. This assignment includes insurance benefits occurring to me under uninsured motorist coverage.
Self-Pay Patients
We offer a self-pay discount to our patients through our Patient Options program. Self-pay rates are $99.00 for our first visit comprised of a $50 exam fee and a $49 dollar adjustment fee. Patients using the self-pay rate cannot be billed to any insurances including auto injury.
Auto injury patients
We accept auto accidents on a lien basis. Our auto cases bill out at full fee rates. Please let us know if you have been in an auto accident and we will send you our auto accident estimated fees.
I UNDERSTAND THAT IF MY INSURANCE COMPANY DENIES ANY CLAIMS FOR MY CARE THAT I WILL ASSUME FINANCIAL RESPONSIBILITY FOR ALL CHARGES. I HAVE READ THE ABOVE INFORMATION AND UNDERSTAND IT.
Please note that a signature below is required in order to receive treatment, if you have any questions or concerns we would be happy to discuss them with you.
ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE
I irrevocably assign and convey directly to the above-named provider, as my designated authorized representative, all insurance benefits, if any, otherwise payable to me for services rendered by provider, regardless of its managed care network participation status. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named provider or their attorneys in order to claim such benefits.
I also assign and/or convey to the above-named provider, as my designated authorized representative, any legal or administrative claim or chosen action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning expenses incurred as a result of services received from the provider. This includes an assignment of ERISA breach of fiduciary duty claims. I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place a lien on) the medical benefits related to the services provided by the above-named provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The above-named provider or their representative is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or actions against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider, as my assignee and my designated authorized representative, may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense. This assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered as valid as original.
I UNDERSTAND THAT IF MY INSURANCE COMPANY DENIES ANY CLAIMS FOR MY CARE THAT I WILL ASSUME FINANCIAL RESPONSIBILITY FOR ALL CHARGES. I HAVE READ THE ABOVE INFORMATION AND UNDERSTAND IT.
Please note that a signature below is required in order to receive treatment, if you have any questions or concerns, we would be happy to discuss them with you.
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
