ACKKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing this form, I certify that I have received a copy of the Notice of Privacy Practices from Excel Medical Diagnostics 1, Inc. and understand its contents. This Notice explains and describes how my private health information may be used and/or disclosed to other parties. I understand that I should read it carefully and I am aware that this Notice may be changed at any time. I may obtain a revised copy of the Notice by calling and/or requesting one from the staff at Excel Medical Diagnostics 1, Inc. I also understand that at any time, the Doctor(s), staff and personnel of Excel Medical Diagnostics 1, Inc. are available to answer and explain any part(s) of the Notice of Privacy Practices which I may not understand.
ASSIGNMENT OF INSURANCE BENEFITS, RELEASE, & DEMAND
Insurer and Patient Please Read the Following in its Entirety Carefully!
I, the undersigned of patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my automobile insurance, a/k/a/ Personal Injury Protection (hereinafter PIP). Uninsured Motorist, and Medical Payments policy of insurance to Excel Medical Diagnostics 1, Inc. I understand it in intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered. I understand this document will allow the provider to file suit against an insurer for payment of the insurance benefits or an explanation of benefits and to seek §627.428 damages from the insurer. If the provider’s bills are applied to a deductible, I agree this will serve as a benefit to me. This assignment of benefits includes the cost of transportation, medications, supplies, overdue interest and any potential claim for common law or statutory band faith/unfair claims handling. If the insurer disputes the validity of this assignment of benefits then the insurer is instructed to notify the provider in writing within five days of receipt of this document. Failure to inform the provider shall result in a waiver by the insurer to contest the validity of this document. The undersigned directs the insurer to pay the health care provider the maximum amount directly without any reductions & without including the patients name on the check. To the extent the PIP insurer contends there is a material misrepresentation on the application for insurance resulting in the policy of insurance is declared voided, rescinded, or canceled, I, as the named insurer under said policy of insurance, hereby assign the right to receive the premiums paid for my PIP insurance to this provider and to file suit for recovery of the premiums. The insurer is directed to issue such a refund check payable to this provider only. Should the medical bills not exceed the premium refunded, then the provider is directed to mail the patient/named insured check, which represents the difference between the medical bills and the premiums paid.
Disputes: The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim that contain or accompanied by language releasing the insurer or its insured/patient from liability unless there has been a prior written settlement agreed to by the health provider (specifically the office manager) and the insurer as to the amount payable under the insurance policy. The insured and the provider hereby contests and objects to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted. If the PIP insurer states it can pay claims at 200% of Medicare then the insurer is instructed & directed to provide this provider with a copy of the policy of insurance within 10 days. Any effort by the insurer to pay a disputed debt as full satisfaction must be mailed to the address above, after speaking with the office manager, and mailed to the attention of the Office Manager. See Fla. §673.31 1.
EUOs and IMEs: If the insurer schedules a defense examination or examination under oath (hereinafter “EUO”) the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider’s attorney is expressly authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer or the patient for any purpose.
This assignment applies to both past and future medical expenses and valid even I undated. A photocopy of this assignment is to be considered as valid as the original. I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts and for any other services unrelated to the automobile accident. The health care provider is given the power of attorney to: endorse my name on any check for services rendered by the above provider; and to request and obtain a copy of any statements or examinations under oath given by patient.
ASSIGNMENT OF INSURANCE BENEFITS, RELEASE, & DEMAND (CONTINUED!)
Release of Information: I authorize this provider to: furnish an insurer, an insurer’s intermediary, the patient’s other medical providers, and the patient’s attorney via mail, fax, or email, with any and all information that may be contained in the medical records; to obtain insurance coverage information (declaration sheet & policy of insurance) in writing and telephonically form the insurer; request from any insurer all explanation of benefits (EOB’s) for all providers and non-redacted PIP payout sheets; obtain any written and verbal statements the patient or anyone else provided to the insurer, obtain copies of the entire claim file and all medical records, including but not limited to, documents, reports, scans, notes, bills, opinions, X-rays, IMEs, and MRIs, from any other medical provider or any insurer. The provider is permitted to produce my medical records to its attorney in connection with any pending lawsuits. The insurer is directed to keep the patient’s medical records from this provider private and confidential. The insurer is not authorized to provide these medical records to anyone without the patient’s and the provider’s prior express written permission.
Demand: Demand is hereby made for the insurer to pay all bills within 30 days without reductions and to mail the latest non-redacted PIP payout sheet and the insurance coverage declaration sheet to the above provider within 15 days. The insurer is directed to pay the bills in the order they are received. However, if a bill from this provider and a claim from anyone else is received by the insurer on the same day the insurer is directed to not apply this provider’s bill to the deductible. If a bill from this provider and claim from anyone else is received by the insurer on the same day then the insurer is directed to pay this provider first before the policy is exhausted. In the event the provider’s medical bills are disputed or reduced by the insurer for any reason, or amount, the insurer is to: set aside the entire amount disputed or reduced; escrow the full amount at issued; and not pay the disputed amount to anyone or any entity, including myself, until the dispute is resolved by a Court. Do not exhaust the policy. The insurer is instructed to inform, in writing, the provider of any dispute.
Certification: I certify that: I have read and agree to the above; I have not been solicited or promised in exchange for receiving health care; I have not received any promises or guarantees from anyone as to the results that may be obtained by any treatment or service; and I agree the provider’s prices for medical services, treatment and supplies are reasonable, usual and customary.
Caution: Please read before signing. If you do no completely understand this document please ask us to explain it to you. If you sign below we will assume you understand and agree to the above.