Monkey Pox Assignment of Benefits

ASSIGNMENT OF ALL RIGHTS AND BENEFITS

Thank you for choosing Rume Medical Group, Inc. (“Provider”) as the provider for your medical treatment. Our goal is to provide you with the highest quality care at an affordable cost. The purpose of this agreement is to notify you of your financial responsibility related to our fee. As a courtesy, we will attempt to verify with your health insurer the benefits available to cover our fee and, as the assignee of your health insurance benefits, will bill your insurance and seek to collect those available benefits. We ask you to read this policy carefully and sign prior to your child receiving our services. If you have any questions about this policy, we encourage you to bring them to our attention.

In exchange for, and in connection with, any and all of the services provided to my dependent (“Services”) by Provider, I hereby assign to Provider 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”). This assignment includes, without limitation, authorization for my insurance carrier or health plan to pay by check made payable and mailed directly to:

________________________________

________________________________

________________________________

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.

I understand that, as a courtesy to me, Provider will file a claim with my insurance company on my behalf. However, I understand and agree 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 Provider 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 Provider 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 Provider’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 Rume Medical Group, Inc., including but not limited to other physicians and laboratories for their services, and that any questions about their bills should be directed to them.

I hereby designate Provider 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 Provider 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.

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 Provider as my authorized representative, as provided above. In the event that my insurance plan pays me directly for the Services, then I will immediately mail such payment to Provider at the address listed above with an endorsement and annotation: “Pay to the Order of ________________.” If it becomes necessary for Provider to file a formal collection action against me, I agree to pay all costs, including reasonable attorneys’ fees, incurred by Provider in the collection of the outstanding fees. I promise to make my best efforts to assist and to cooperate with Provider as needed or reasonably requested by Provider 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.


I have read, understand, and fully agree to this Assignment of All Rights and Benefits.


Patient:
Signed: __________________________ Date: ____
Print Name: ____________________________________________