This office does not accept responsibility for collecting your insurance proceeds or negotiating the settlement of a disputed claim. If, for whatever reason, your insurance company does not pay your claim in full, you are responsible for payment of the entire balance, including any finance charges or collection fees that may be included.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.

I understand and agree to pay the $25 fee for requesting a hard copy of my medical records and any other added paperwork I would like the doctor to fill out. I understand that I will need to allow 72 hours for my medical records to be processed and 2 weeks for forms to be filled out.

I understand that should I need any refills on my medications, they should be requested during my appointment with the doctor. I know that should I make any requests outside of this time, I must allow 3-5 business days for my prescriptions to be filled. I take responsibility for calling the office in the appropriate time frame for my medications to be refilled before I run out.

I hereby assign and convey directly to the above named health care provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, If any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above -named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above named health care provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above named health care provider or its attorneys in order to claim such medical benefits.
In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort Feas or insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.
l 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, treatments, therapies, and/or mediations provided by the above named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above - named provider) 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 chose in action or right 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 lifetime assignment will remain in effect until revoked by me in writing. It is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it were the original.

I have reviewed this office’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.