Common use of ASSIGNMENT OF INSURANCE BENEFITS Clause in Contracts

ASSIGNMENT OF INSURANCE BENEFITS. I acknowledge that I am responsible for paying ambulance services provided to me by Sunstar, except those eligible under the Membership. I acknowledge that Sunstar will file claims on my behalf with my primary and secondary (if applicable) insurance carrier(s) including Medicare. I herein assign my right to reimbursement for covered transports to Sunstar. INSURANCE PAYMENT OF CLAIMS: I authorize payment resulting from claims billed on my behalf be made directly to Sunstar. In the event I receive payment directly from my insurance company related to the transport, I agree to endorse the check, include explanation of benefits and mail to: Sunstar at P.O. Box 31074, Tampa, FL 33631-3074. If I do not forward the payment to Sunstar, I understand I will receive a bill and be responsible for the payment of this amount. RELEASE OF MEDICAL INFORMATION: As a part of the billing process, I authorize release of any holder of medical information about me or other relevant documentation about me to release to Centers for Medicare and Medicaid Services and its agents and contractors, any and all appropriate third party payers and their respective agents and contracts, as well as Sunstar, any information or documentation in their possession needed to determine these benefits and/or the benefits payable for related service, whether in the past, now or in the future.

ASSIGNMENT OF INSURANCE BENEFITS. I acknowledge that I am responsible for paying ambulance services provided to me by Sunstar, except those eligible under the Membership. I acknowledge that Sunstar will file claims on my behalf with my primary and secondary (if applicable) insurance carrier(s) including Medicare. I herein assign my right to reimbursement for covered transports to Sunstar. INSURANCE PAYMENT OF CLAIMS: I authorize payment resulting from claims billed on my behalf be made directly to Sunstar. In the event I receive payment directly from my insurance company related to the transport, I agree to endorse the check, include explanation the Explanation of benefits Benefits (EOB), and mail to: Sunstar at P.O. Box 31074, Tampa, FL 33631-3074. If I do not forward the payment to Sunstar, I understand I will receive a bill and be responsible for the payment of this amount. RELEASE OF MEDICAL INFORMATION: As a part of the billing process, I authorize release of any holder of medical information about me or other relevant documentation about me to release to the Centers for Medicare and Medicaid Services and its agents and contractors, any and all appropriate third party payers and their respective agents and contracts, as well as Sunstar, any information or documentation in their possession needed to determine these benefits and/or the benefits payable for related service, whether in the past, now or in the future.