Common use of ASSIGNMENT OF INSURANCE BENEFITS Clause in Contracts

ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to Provider. I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles. Authorization to Release Information I hereby authorize Provider to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and(3) allow a photocopy of my signature to be used to process insurance claims I understand that any information disclosed pursuant to this authorization may be disclosed by the recipient pursuant to my providers Notice of Privacy disclosure and may not be protected by the federal privacy regulation. I understand that I have a right to revoke this authorization at any time by providing written notice to my Provider and my health benefit plan (or its administrator) via electronic mail, U.S. mail or facsimile. I further understand that there are no exceptions to my rights to revoke this authorization. Therefore, this authorization will remain in force and effect for claims with date of service within one year of the signature date, or until revoked by me in writing, or until my healthcare claims are adjudicated to my provider’s satisfaction.

ASSIGNMENT OF INSURANCE BENEFITS. To the extent permitted by law, I hereby irrevocably assign to CNE Site and other providers furnishing services to the patient any and all applicable health benefits of any type arising out of any claim or policy of insurance insuring the patient or any willing party liable to the patient. I authorize and request that payment of insurance benefits be made on my behalf for any services furnished to which I and/or my dependents are entitled to Providerme by or in the CNE Site, including provider services. FEDERAL MEDICARE BENEFITS: I certify that the health insurance information that I provided to Provider is accurate as given by me in applying for payment under Title XVIII of the date set forth below Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or the Medicare program or their intermediaries or other agents any information needed for this or a related Medicare claim. I request payment of authorized benefits be made on my behalf. I assign the benefits payable for provider services to the provider or organizations furnishing the services or authorize such provider or organization to submit claims to Medicare for payment to me. I acknowledge and that agree that, to the extent permitted by law, I am responsible for keeping it updatedpayment for any services provided not covered by Medicare. FINANCIAL AGREEMENT/GUARANTEE OF PAYMENT: I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand acknowledge that I am legally responsible for all amounts charges incurred in connection with medical care and treatment provided by CNE Site and providers providing professional services to me through the CNE Site (hereinafter “Providers”). I agree and consent to medical care that has been or will be provided to the patient whose name appears above. For services rendered by the CNE Site and Providers, I guarantee payment of the account and agree to pay such account at the time services are rendered if payment for such services are not covered by my health insurance, including co-payments, co-insurance, and deductibles. Authorization to Release Information I hereby authorize Provider to: insurance carrier or other third- party payer (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and(3) allow a photocopy of my signature to be used to process insurance claims I understand that any information disclosed pursuant to this authorization may be disclosed by the recipient pursuant to my providers Notice of Privacy disclosure and may not be protected by the federal privacy regulation“Payer”). I understand that Payer may require authorization prior to my receiving treatment and that it is my responsibility to obtain that prior authorization and know the coverage of my plan. I understand that receiving prior authorization does not guarantee that my Payer will pay because the benefits permitted depend upon my individual healthcare plan. I understand that Providers may not balance bill me for non-emergency services provided to me at a CNE Site if Providers are out-of- network with my Payer, unless I receive prior notice by and provide consent to CNE Site or Providers. I acknowledge that if my child/dependent is cared for by CNE Site or Providers I will be responsible for payment for services provided under these same terms and conditions. COMMUNICATIONS: By signing this consent, I understand and agree that CNE Site can use my telephone number, cell phone number, mailing address or email address I have a right provided in order to revoke this authorization at any time by providing written notice send messages. Messages may include, but not limited to, appointment reminders, patient portal message notification, surveys, questionnaires or billing/payment issues. By agreeing to these electronic transmissions, I acknowledge that the privacy and security of electronic communications cannot be guaranteed and that parties with whom I have chosen to share electronic addresses or phone numbers may be aware of such transmissions and may have the means to access my Provider and my personal health benefit plan (or its administrator) via electronic mail, U.S. mail or facsimile. I further understand that there are no exceptions to my rights to revoke this authorization. Therefore, this authorization will remain in force and effect for claims with date of service within one year of the signature date, or until revoked by me in writing, or until my healthcare claims are adjudicated to my provider’s satisfactioninformation using information from these transmissions.

ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to ProviderPractice. I certify that the health insurance information that I provided have provide to Provider provider is accurate as of the date set forth below and that I am responsible for keeping it updatedupdating all health insurance information. I hereby authorize Provider Practice and any affiliates on behalf of me and my healthcare provider to submit claimsclaims on my, on my and/or my dependent’s behalf, 's behalf to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) administrator to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to ProviderPractice, I hereby instruct and direct my benefit plan (or for its administrator) to provide documentation stating such non-assignment to myself and Provider my provider upon request. request Upon proof of such non-non assignment, . I instruct my benefit plan (or for its administrator) administrator to make out the check to me and mail it directly to Provider. my healthcare provider I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by to pay my health insurance, including co-payments, co-insurance, deductible and deductibles. coinsurance Authorization to Release Information I hereby authorize Provider my health care provider to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and(3treatment and (3) allow a photocopy copy of my signature to be used to process insurance claims I understand that any information disclosed pursuant to this authorization may be disclosed by the recipient pursuant to my providers Notice of Privacy disclosure and may not be protected by the federal privacy regulationclaims. I understand that I have a right to revoke this authorization at any time by providing written notice to my Provider and my health benefit plan (or its administrator) via electronic mail, U.S. mail or facsimile. I further understand that there are no exceptions to my rights to revoke this authorization. Therefore, this authorization This onder will remain in force and effect for claims with date of service within one year of the signature date, or until revoked by me in writing. ERISA Authorization I hereby designate, authorize, and convey to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan as my Authorized Representative: (1) the right and ability to act on my behalf in connection with any claim right, or cause of action that I may have under such insurance policy andior benefit and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan including but not limited to the right to including, but not limited to, pursuing available administrative appeals or filing suit and all other causes of action on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 CFR 2560.503140 with respect to any healthcare expense incurred as a result of services I received from my provider and Practice and, to the extent permissible by law, to claim on my behalf such benefits, claims, reimbursement, and any other applicable remedy, including fines. A copy of this Assignment Authorization shall be as effective and valid as the original. RESOLUTION AGREEMENT & MEDIATION We pride ourselves on our careful and kind care. Mediation has been show to expedite the resolution process of any concerns. We encourage open communication and ask our patients to sign this agreement in which we make contract commitments to each other. It is no surprise that frivolous malpractice claims have a negative impact on healthcare care and can harm the practice and livelihood of a healthcare provider. Therefore, an additional consideration for professional care provided to me by Provider, the penguardian andor my representative agree not to advance, directly or indirectly, any false mentless, andor frivolous claim of healthcare malpractice against Provider. Furthermore, in the event of a meritorious malpractice case or cause of action and/or my representative agree to use expert healthcare witnesses practicing in the same specialty as Provider. I agree that these expert witnesses will be members in good standing of their state board In further consideration for this. Provider agrees to the same stipulations Patient/guardian and Provider acknowledge that monetary damages may not provide an adequate remedy for breach. Such breach may result in imeparable harm to Provider's reputation and business. Patient/guardian and Provider agree in the event of a breach to allow specific performance and injunctive relief MEDIATION While we do not anticipate any issues during the course of your treatment, if any arise, you and your healthcare provider agree to meet with a neutral mediator for a voluntary conversation before starting formal legal action Should a concern arise regarding the healthcare provided by this office, staff, and affiliated healthcare professionals, I agree to mediate first before pursuing legal action 1 agree that any usage or inference to a "claim" will be understood and read as "potential claim" until my mediation is complete. This designation allows us to begin in a less formal manner that has been shown to expedite the resolution process. I will also not make any demand for payment before mediation begins 1 agree that offering to mediate is a mandatory prerequisite to litigation, and that fea lawsuit without first demanding mediation, the lawsuit should be dismissed without prejudice this perquisite has been met agree that this mediation provision is a material part of this contract I UNDERSTAND THAT I DO NOT HAVE TO HIRE AN ATTORNEY TO MEDIATE, BUT IF CHOOSE TO CONSULT WITH AN ATTORNEY. I WILL SHOW HIM OR HER THIS PROVISION Filing in any court by the Provider to collect fees shall not waive the right to compel mediation of any claims. COMPLIANCE & TEAMWORK We want you to receive excellent care. The best way to meet this goal is good communication. YOUR COMMITMENT Ask questions and be part of your care Be honest about your health history and symptoms Tell your doctor about any health changes Schedule based on the recommended care plan Prepare for and keep scheduled visits or reschedule visits in advance whenever possible De respectful to office staff and healthcare claims are adjudicated providers End every visit with a clear understanding of your doctor's expectations, and treatment goals OUR COMMITMENT Explain diagnosis, treatment recommendations and outcomes in an easy-to-understand way Listen to my provider’s satisfaction.your questions Keep treatments, discussions, and records private Determine when a breakdown of the doctor-patient relationship is justification for terminating care Determine when referal to another provider or Share patient information with other providers involved in your healthcare, as appropriate

ASSIGNMENT OF INSURANCE BENEFITS. I hereby assign to Atrium Health all applicable health insurance benefits my rights to which I and/or my dependents are entitled receive payments of all amounts due to Provider. I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the me under every benefit plan (and insurance policy that may provide compensation or its administrator) listed on payment to me, including but not limited to medical, hospital and outpatient insurance and benefit policies and plans, sick benefits, Med-Pay benefits, and injury judgments and settlements, including awards, amounts, and benefits due to me under my own insurance policy/ies or under the current insurance card I provided to Providerpolicy/ies of any other person or entity, in good faithsuch as auto insurance or workers’ compensation insurance. I also hereby instruct my benefit plan (assign to Atrium Health the proceeds of all insurance claims and judgments payable by any person, entity, employer or its administrator) insurance company to pay Provider directly or for services rendered me. These assignments are effective to me or my dependents. To the fullest extent that my current policy prohibits direct payment not prohibited by law and up to Provider, the full amount I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible owe for all amounts not covered by my health insurance, including co-payments, co-insuranceServices provided to me, and deductibles. Authorization to Release Information I hereby authorize Provider to: direct payment of all amounts I am entitled to receive that are covered by these assignments to Atrium Health or, at Atrium Health’s request or direction, to Atrium Health’s wholly and partly owned direct and indirect subsidiaries, its affiliated entities, entities it manages, my providers, and professional groups or entities contracted by Atrium Health for Services provided to or performed for me (1) release any information necessary all referred to my health benefit plan (herein as “Payees”), including but not limited to Payees providing radiology and imaging, anesthesia and pain, pathology, radiation oncology, and emergency medicine Services. I warrant and represent that every insurance policy providing payments or its administrator) regarding my illness amounts assigned herein is valid and treatments; (2) process insurance claims generated in effect and that I have the course of examination or treatment; and(3) allow a photocopy of my signature right thereunder to be used to process insurance claims I understand that any information disclosed pursuant to make this authorization may be disclosed by the recipient pursuant to my providers Notice of Privacy disclosure and may not be protected by the federal privacy regulationassignment. I understand that I am financially responsible to each Payee for all amounts I owe or that are due to such Payee even if not covered by this assignment. For example, I know that sometimes insurance companies will not pay for Services ordered by my providers and which I have authorized. I understand that these payment denials occur for a right variety of reasons. My insurance policy may not include the particular Service as a benefit. In other cases, a Service will not be covered by my insurance company because it decides the Service is not necessary, despite my provider’s decision to revoke this authorization at order the service. In any time event, even if a Service is not covered by providing written notice insurance, I agree to pay for all charges for all Services rendered, including the specific Services rendered as part of medical treatment. If Atrium Health deems it necessary, I authorize Atrium Health to file member grievances or appeals on my Provider and behalf with my health benefit plan (for any denied claims. I appoint representatives of Atrium Health to act as my representative in pursuing such grievances or appeals. I authorize Atrium Health, at its administrator) via electronic maildiscretion and own expense, U.S. mail to obtain legal representation to assist in connection with grievances or facsimileappeals. I further understand agree that there are no exceptions each Payee may apply any excess reimbursements or payments to any other indebtedness or amount owed by me, my rights to revoke this authorization. Therefore, this authorization will remain in force and effect for claims with date of service within one year of the signature datespouse, or until revoked by me in writing, or until my healthcare claims are adjudicated to my provider’s satisfactionany child for whom I am financially responsible.