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 dependent (“Services”) by Driven Care, Inc, Campus Physicians of California, P.C. or other appointed Health Care Provider (“HCP”), MedLab2020, Inc, Covid Clinic, Inc. or other Laboratory Service Provider (individually “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 had, have or may have in the future pursuant to or in connection with any insurance policy or plan, 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 my dependent. This assignment includes, without limitation, authorization for my insurance carrier or health plan to pay by check.
This assignment 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 Provider 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 Provider, this assignment is irrevocable. I instruct my insurance company to pay LSP and / or HCP directly for the professional or medical expense benefits 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 insurance company 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 insurance or any balance not covered by the insurance payment. I understand that HCP and/or LSP reserves the right to require that, when required by 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 insurance will cover any or all of the Services, and that I am not relying on any representations by Provider regarding the amount of plan benefits applicable to the Services prior to the claim being processed by insurance. 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.
AGREEMENT TO COOPERATE: I hereby agree to cooperate with, and take all steps necessary, required or reasonably requested by Provider to effectuate, perfect, confirm, validate or enforce my Assignment of Rights and Benefits to Provider or authorization of HCP and/or LSP as my authorized representative, as provided above. In the event that my insurance plan 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 and to the order of the entity I am instructed to provide. If 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 Provider in order to exercise, secure or enforce any Rights. If I do not provide my insurance information, I authorize Campus Clinic, LLC perform insurance discovery to locate my insurance information based on other information I provide and to provide the insurance information to the LSP and/or HCP.
NO OUT OF POCKET COST SERVICES:
I understand that certain services will be provided to me at no out of pocket cost. I am still however responsible to provide my insurance information so that they are billed for the costs associated with these services. These services include:
I have read, understand, and fully agree to this Assignment of All Rights and Benefits.