Assignment of Benefits

INSURANCE AUTHORIZATION AND ASSIGNMENT:
I certify that all information I have provided to Emerald Medical Practice P.C. (the “Practice”) is true and correct. I hereby authorize payment of any medical benefits made on my behalf directly to the Practice provider of service(s) furnished to me. I authorize and direct the Practice to release any medical information to my health insurance carrier and/or its agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards and the Practice Notice of Privacy Practices. I hereby assign, transfer and authorize payment of service(s), otherwise payable to me under the terms of my private, group employer’s or group health insurance plan, directly to the Practice.

PRE-AUTHORIZATION RESPONSIBILITY: I understand that it is the insurer’s responsibility to review anticipated courses of treatment. I understand that if the insurer determines that the treatment plan is necessary and appropriate and Authorizes services, the benefits of my health plan will be available to me according to my policy terms. However, if authorization is denied, benefits may be withheld. I understand that obtaining necessary pre-authorization is the responsibility of the patient, financially responsible party, and /or the referring physician. I also understand that I will be financially responsible for any and all related charges incurred as a result of this treatment plan should the insurer either refuse to pre-authorize the treatment or retrospectively determine that a specific service was inappropriate, or should the authorization occur too late to be valid. I understand that to protect myself from unnecessary personal financial obligations, I must review my obligations with my insurance company and personal physician in advance of my appointment.

FINANCIAL RESPONSIBILITY: I understand that the Practice is acting solely as agent for filing insurance benefits assigned to it; however the Practice assumes no responsibility for guaranteeing payment of covered charges. I understand that my insurance company is being billed as a courtesy to me and that I am financially responsible for charges not covered by the Assignment of Benefits. One such charge may be my patient responsibility as dictated by a deductible, co-insurance, or co-payment responsibility required by my insurance carrier. The Practice may require an up-front payment by me for the estimated patient responsibility. I understand that any amount collected by the Practice from me is considered only an estimate until such time as the claim has been fully processed by my insurance carrier. I agree to make full payment immediately upon receipt of a Practice billing statement whether it is an interim or final bill. In the event that I fail to make full payment or fail to comply with other payment arrangements made with the Practice’s approval, I understand that appropriate collection measures may be initiated.

I, or my legal representative, certify that I have read this document, that it has been fully explained to me and that I understand its contents, and hereby agree to all terms and conditions set forth above and acknowledge the receipt of a copy if requested. I hereby authorize that photocopies of this form to be valid as the original.