Insurance/Authorization. Consultant shall carry adequate liability, property, workers’ compensation, umbrella and other insurance of a kind and in an amount generally carried by persons engaged in the same or a similar kind of business similarly situated, unless, in any case, other types of insurance or higher amounts are required by the College as may be identified on an exhibit hereto or otherwise communicated to Consultant, in all cases naming the College as an additional insured where required by the College. Upon request, Consultant shall supply to the College a certificate(s) of insurance evidencing the same, where required. Consultant hereby represents, warrants and covenants to College that it has and/or will have and maintain all necessary permits, license, approvals and other authorizations applicable to the performance of its obligations contemplated under this Agreement. Consultant shall observe all policies, rules, regulations and instructions that College may promulgate or deliver to Consultant from time to time, all of which shall form a part of this Agreement upon delivery thereto.
Insurance/Authorization. Sponsor authorizes ROP to provide Student’s medical insurance information to any person performing medical or other services, providing medication or doing anything else on behalf of Student described herein that may be covered by Student’s medical insurance plan.
Insurance/Authorization. The School understands and agrees that neither UPMC nor the Athletic Trainer, Physician or Trainee will secure insurance authorization or verifications of insurance coverage for any Student-Athletes.
Insurance/Authorization. Company shall carry adequate liability, property, worker’s compensation, umbrella and other insurance of a kind and in an amount generally carried by persons engaged in the same or a similar kind of business similarly situated. Company hereby represents, warrants and covenants to Client that it has and/or will have and maintain all necessary permits, license, approvals, and other authorizations applicable to the performance of its obligations contemplated under this Agreement.
Insurance/Authorization. Consultant shall carry adequate liability, property, workers’ compensation, umbrella and other insurance of a kind and in an amount generally carried by persons engaged in the same or a similar kind of business similarly situated, unless, in any case, other types of insurance or higher amounts are required by the University as may be identified on an exhibit hereto or otherwise communicated to Consultant, in all cases naming the University as an additional insured where required by the University. Upon request, Consultant shall supply to the University a certificate(s) of insurance evidencing the same, where required. Consultant hereby represents, warrants and covenants to University that it has and/or will have and maintain all necessary permits, license, approvals and other authorizations applicable to the performance of its obligations contemplated under this Agreement.
Insurance/Authorization. Assignment of Insurance Benefits: I hereby authorize payment of medical benefits directly to Xxxx Pediatrics. I further authorize the release of any medical information necessary for processing the insurance claim and any referral necessary for the care of the patient. I permit a copy of this authorization to be as valid as the original. I understand that all costs not paid by the insurance will become my responsibility unless otherwise prohibited by state or federal regulations. I understand that if I do not inform Xxxx Pediatrics of changes in my insurance coverage within 30 days from the date of service that I may be responsible for any charges incurred due to a delay in timely submission of charges. MEDICARE LIFETIME AUTHORIZATION If the patient is covered by Medicare/Medicaid, I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical information about the minor child named herein above to release to the Social Security Administration, it’s agencies, intermediaries, or carriers, any information needed for this or a related Medicare claim. I request that the payment of authorized benefits be made on the patient’s behalf I assign the benefit payable for physician services to Xxxx Pediatrics or the organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I also authorize Xxxx Pediatrics or the organization to appeal any denial of benefits on the patient’s behalf. PATIENT FINANCIAL RESPONSIBILITY AGREEMENT Insurance Claims/Payment: As a courtesy, Xxxx Pediatrics will file your insurance claims for you; however, in the event that your insurance company denies payment for any reason or has not paid within 45 days, the parent(s) and/or guarantor will be responsible for any balance due. It is also the parent(s) and/or guarantor’s responsibility to provide current insurance information, including the insurance subscriber number and mailing address, and to follow up on any benefit questions with the insurance carrier. You are responsible for informing Xxxx Pediatrics of changes in insurance coverage within 30 days from the date of service, you may be responsible for any charges incurred due to delay in timely submission of charges. We must emphasize that we are a medical care provider; our relationship is with the patient and not the insurance company. While the filing of insurance claims is a...
Insurance/Authorization. For clients who have insurance coverage for the services provided, JSSA will directly bill the insurance company (ies). Clients are required to pay the estimated co-payment and any unmet deductible PRIOR to service. JSSA cannot guarantee payment from any insurance company. Clients are responsible for paying all balances not reimbursed by the insurance company (ies). Clients are responsible to know their insurance coverage, benefits and provide JSSA with any necessary referrals. I hereby irrevocably authorize my insurance company (ies) to pay JSSA directly on my behalf for services provided. I authorize JSSA to submit claims and release medical information (including information regarding drug and/or alcohol related condition/treatment) to my insurance company (ies). Responsible Party Date
Insurance/Authorization. Sponsor authorizes OWP to provide Student’s medical insurance information to any person performing medical or other services, providing medication or doing anything else on behalf of Student described herein that may be covered by Student’s medical insurance plan.
Insurance/Authorization. I hereby authorize payment directly to Bridgeland Dental Care, for services rendered, otherwise payable to me. I authorize the releases of any information relating to my dental claims through this office.
Insurance/Authorization. Some insurance companies require authorization for consultation and treatment. The undersigned understands that this arrangement is between him/her and his/her insurance company and that if such authorization is needed, he/she is responsible for obtaining and submitting it to the office of NorCal Endocrinology & Internal Medicine prior to each visit with the medical providers at NorCal Endocrinology & Internal Medicine. The undersigned understands that he/she needs to bring a copy of the authorization to the appointment. The undersigned understands and agrees that he/she is responsible for all charges for medical/consultative services rendered whether or not insurance authorization was obtained. Financial Agreement The undersigned agrees that he/she is personally responsible for the total fees he/she may have incurred at the time of visit. The undersigned understands that all services are due in full within thirty
