ASSIGNMENT OF ALL RIGHTS AND BENEFITS: In exchange for, and in connection with, any and all of the services provided to me and/or my child(ren) (“Services”) by Rume Medical Group, Inc., Campus Physicians of California, P.C. or other appointed health care provider (each, an “HCP”), MVML, Inc., MedLab2020, Inc, Covid Clinic, Inc. or other laboratory service provider (each, an “LSP”), I hereby assign to HCP and/or LSP all of my rights, benefits, privileges, protections, claims and any other interests of any kind whatsoever, without limitation, that I and/or my child(ren) had, have or may have in the future pursuant to or in connection with any insurance policy or plan, health benefit plan (including an employee health benefit plan), health management agreement, risk-bearing agreement, trust, fund or any other source of payment, insurance, indemnity or health or medical coverage of any kind (collectively, “Health Coverage”) covering me and/or my child(ren). This assignment includes, without limitation, authorization for my and/or my child(ren)’s Health Coverage to pay HCP and/or LSP by check.
This assignment to HCP and/or LSP also includes appeal rights (both internal and external), fiduciary rights, rights to sue, rights to payment, rights to full and fair claims review, rights to penalties or interest, rights to plan documents and plan information, and rights to notices and disclosures from any source (collectively, “Rights”). I am hereby transferring to HCP and/or LSP all of these Rights under any Health Coverage to which I am now, previously, or may be entitled to in the future with respect to the Services. Unless otherwise agreed between me and HCP and/or LSP or as otherwise provided by applicable law, this assignment is irrevocable. I instruct my Health Coverage to pay LSP and/or HCP directly for the professional and/or medical expense benefits otherwise payable to me.
ACKNOWLEDGEMENT OF CLIENT FINANCIAL RESPONSIBILITY: I understand that, as a courtesy to me, HCP and/or LSP will file a claim with my Health Coverage on my behalf. However, I understand and agree that unless otherwise indicated in writing below, by signing below that I am financially responsible for, and hereby do agree to pay, in a timely manner, charges not covered under my Health Coverage or any balance not covered by the Health Coverage payment. I understand that HCP and/or LSP reserves the right to require that, when permitted by applicable law, I pay any unmet deductible or co-payment required by my Health Coverage or other deposit prior to providing the Services. I understand that HCP and/or LSP makes no guarantees that my Health Coverage will cover any or all of the Services, and that I am not relying on any representations by HCP and/or LSP regarding the amount of plan benefits applicable to the Services prior to the claim being processed by my Health Coverage. I acknowledge that I have had a reasonable opportunity to inquire about HCP and/or LSP’s charges and that my questions regarding its charges, including any questions regarding a reasonable estimate of the total amount of the charges, have been answered. I understand that I may also be receiving separate bills from providers not affiliated with HCP and/or LSP, including but not limited to other physicians and laboratories for their services, and that any questions about their bills should be directed to them.
APPOINTMENT OF AUTHORIZED REPRESENTATIVE: I hereby designate HCP, LSP and/or its designated agents and representatives as my duly authorized representative(s) in connection with all matters arising from or relating to Rights and Health Coverage, such that HCP and/or LSP completely and without reservation “stands in my shoes” and takes my place for all applicable purposes, and is granted absolute power and legal authority to seek, claim, and directly receive payment or reimbursement for Services; challenge or appeal any adverse benefit determination of any kind whatsoever; or take any other action or obtain anything that I would have been entitled to do, seek, claim, appeal or obtain in my own capacity pursuant to or in connection with the Rights in any legal, private, administrative, formal or informal process or forum whatsoever and without limitation, including any internal or external appeal, review, grievance or any other process, procedures or entitlement.
ERISA AUTHORIZATION: With respect to Health Coverage governed by the provisions of the Employee Retirement Income Security Act of 1974 (ERISA), this Assignment of Benefits authorizes HCP and/or LSP to act as my authorized representative under 29 C.F.R. section 2560.5031(b)(4) to seek, claim, and directly receive payment or reimbursement for Services; challenge or appeal any adverse benefit determination of any kind whatsoever; or take any other action or obtain anything that I would have been entitled to do, seek, claim, appeal or obtain in my own capacity pursuant to or in connection with the Rights in any legal, private, administrative, formal or informal process or forum whatsoever and without limitation, including any internal or external appeal, review, grievance or any other process, procedures or entitlement.
AGREEMENT TO COOPERATE: I hereby agree to cooperate with, and take all steps necessary, required or reasonably requested by HCP and/or LSP to effectuate, perfect, confirm, validate or enforce this Assignment of Benefits. I hereby authorize HCP and/or LSP to execute on my behalf any document, including, without limitation, any document required by my Health Coverage, that is necessary to demonstrate that I have designated HCP and/or LSP as my authorized representative for the purposes set forth in this Assignment of Benefits. If necessary, I consent to a photocopy of my signature to be added to any document that is necessary to demonstrate that I have designated HCP and/or LSP as my authorized representative for the purposes set forth in this Assignment of Benefits. In the event that my Health Coverage pays me directly for the Services, then I will immediately notify Campus Clinic by email at email@example.com and mail such payment to HCP and/or LSP at the address provided to me, payable to the order of the entity I am instructed to list. If I do not forward the payment or make separate payment to HCP and/or LSP of the amount I received from my Health Coverage, and it becomes necessary for HCP and/or LSP to file a formal collection action against me, I agree to pay all costs, including reasonable attorneys’ fees, incurred by HCP and/or LSP in the collection of the outstanding fees. I promise to make my best efforts to assist and to cooperate with HCP and/or LSP as needed or reasonably requested by HCP and/or LSP in connection with any action in any forum, whether legal, formal or informal, without limitation, commenced or maintained by HCP and/or LSP in order to exercise, secure or enforce any Rights.
NO OUT OF POCKET COST SERVICES: I understand that certain services may be provided to me at no out of pocket cost. I am still, however, responsible to provide my Health Coverage information so that my Health Coverage is billed for the costs associated with these services.
ACKNOWLEGEMENT OF INSURANCE DISCOVERY: I understand that if I do not provide information to HCP and/or LSP about any Health Coverage under which I and/or my child(ren) may be entitled to benefits, or if the Health Coverage that I identify to HCP and/or LSP does not cover the services I or and/or my child(ren) may receive from HCP and/or LSP in full, then HCP and/or LSP, by itself or using an outside entity, may attempt to locate Health Coverage that is be available to cover the costs of the services provided by HCP and/or LSP. I hereby consent to HCP and/or LSP, or any outside vendor engaged by HCP and/or LSP, to search for such Health Coverage using all legal means available, and if such Health Coverage is located, I hereby consent to HCP and/or LSP submitted a claim to that Health Coverage in accordance with this Assignment of Benefits.
CONSENT TO TEXT MESSAGES, TELEPHONE CALLS AND/OR EMAILS: I understand that by providing my phone number and email address below, I consent to receive text messages, telephone calls and/or emails at the number and/or email address provided, which may be automated or prerecorded in nature, from Campus Clinic, HCP, LSP and/or their affiliates and partners related to (1) obtaining information relating to my Health Coverage, and/or (2) assisting me in obtaining Health Coverage for myself and/or my child(ren), including without limitation coverage under state government programs. I acknowledge my consent to receiving these messages is not a condition of purchasing or receiving any service from HCP, LSP, and/or their affiliates and partners. I can opt-out of receiving these messages at any time. Message & data rates may apply.
SIGNATURE: I have read, understand, and fully agree to this Assignment of Benefits.
I am signing on my own behalf, in connection with services to be rendered to me:
I am signing on behalf of my minor child(ren), in connection with services rendered to them: