Common use of Insurance Information Clause in Contracts

Insurance Information. If you have a health insurance policy, it may provide some coverage for mental health services. • Our office will obtain the necessary pre-authorization for services. You do not need to call do obtain authorization. However, it is helpful to find out exactly what mental health benefits you do have such as your specialist copay, deductibles, maximum number of appointments per year, exclusionary diagnoses, etc. • You are responsible for paying your copay, co-insurance and amounts applied to your deductible. There are occasions when we are misquoted by insurance companies. You are responsible for understanding your policy and paying the difference if we are misquoted by your insurance company. • If services are denied by your insurance company for any reason, you are responsible for covering the full cost of the service rendered. • Always check your Explanation of Benefits (EOB) to make sure that you are paying the correct copay or co-insurance amount, and that you satisfy your deductible, if applicable. You will likely receive your EOB before we receive a copy. If there is a difference, please let us know as soon as possible so we can remedy the situation. Patient refunds are typically conducted on a quarterly basis, unless otherwise requested. • If you have a deductible, it is your responsibility to keep up with it being met; as we do not have access to other providers you have seen. Please remember that deductibles are typically based on when claims are submitted not when the service was rendered. • If your child is seeing another mental health provider, please contact your insurance company to determine if your child can be treated by two mental health providers at the same time. Most policies do not allow a child to have two psychologists or mental health counselors at the same time and you may have to cancel an existing authorization for the new provider to be covered. In some cases, insurance may also not cover psychiatry visits if seen on the same day as we provide services, depending on which codes your psychiatrist bills. In such instances, you may have to choose between the two providers, or pay out of pocket for the service not covered under the insurance policy. • There are also situations in which insurance will deny coverage if your child has a pre-existing condition. This typically occurs when you have switched insurance carriers and not reported a mental health diagnosis. Please check your benefits to make sure there is not a waiting period for your mental health benefits to begin. We are not told up front if you have an exclusionary pre-existing condition clause and you will be responsible for payment if services are denied. • If your insurance carrier changes please let us know as soon as possible, before your child’s next appointment. We make every effort to obtain your insurance authorization and benefits before your appointment. If authorization is not obtained before the appointment, the appointment may not be covered and you may be responsible for payment. • You should also be aware that your contract with your insurance company requires that we provide information relevant to the services that we provide to you. We are required to provide a clinical diagnosis.

Insurance Information.  If you have a health insurance policy, it may provide some coverage for mental health services. •  Our office will obtain the necessary pre-authorization for services. You do not need to call do obtain authorization. However, it is helpful to find out exactly what mental health benefits you do have such as your specialist copay, deductibles, maximum number of appointments per year, exclusionary diagnoses, etc. •  You are responsible for paying your copay, co-insurance and amounts applied to your deductible. There are occasions when we are misquoted by insurance companies. You are responsible for understanding your policy and paying the difference if we are misquoted by your insurance company. •  If services are denied by your insurance company for any reason, you are responsible for covering the full cost of the service rendered. •  Always check your Explanation of Benefits (EOB) to make sure that you are paying the correct copay or co-insurance amount, and that you satisfy your deductible, if applicable. You will likely receive your EOB before we receive a copy. If there is a difference, please let us know as soon as possible so we can remedy the situation. Patient refunds are typically conducted on a quarterly basis, unless otherwise requested. •  If you have a deductible, it is your responsibility to keep up with it being met; as we do not have access to other providers you have seen. Please remember that deductibles are typically based on when claims are submitted not when the service was rendered. •  If your child is seeing another mental health provider, please contact your insurance company to determine if your child can be treated by two mental health providers at the same time. Most policies do not allow a child to have two psychologists or mental health counselors at the same time and you may have to cancel an existing authorization for the new provider to be covered. In some cases, insurance may also not cover psychiatry visits if seen on the same day as we provide services, depending on which codes your psychiatrist bills. In such instances, you may have to choose between the two providers, or pay out of pocket for the service not covered under the insurance policy. •  There are also situations in which insurance will deny coverage if your child has a pre-existing condition. This typically occurs when you have switched insurance carriers and not reported a mental health diagnosis. Please check your benefits to make sure there is not a waiting period for your mental health benefits to begin. We are not told up front if you have an exclusionary pre-existing condition clause and you will be responsible for payment if services are denied. •  If your insurance carrier changes please let us know as soon as possible, before your child’s next appointment. We make every effort to obtain your insurance authorization and benefits before your appointment. If authorization is not obtained before the appointment, the appointment may not be covered and you may be responsible for payment. •  You should also be aware that your contract with your insurance company requires that we provide information relevant to the services that we provide to you. We are required to provide a clinical diagnosis.

Insurance Information. If you Please provide us with your insurance contact information, where we can request certificate of insurance with specific holders. (i.e. brokers and/or shippers) INSURANCE WEB ADDRESS CITY ST ZIP CONTACT E-MAIL PHONE # FAX # Dispatch + Carrier = Agreement Initials MDH / This Limited Power of Attorney (AGREEMENT) is made effective on (date) between: HighRise Trucking & Logistics LLC. hereinafter called DISPATCH a company established under the laws of the State of North Carolina, and hereinafter called CARRIER, motor carrier company with MC # . CARRIER hereby appoints DISPATCH as my Attorney-in-Fact (AGENT). DISPATCH’s agents shall have full power and authority to act on my behalf. This power and authority shall authorize DISPATCH to manage and conduct affairs and to exercise all of my legal rights and powers, including all rights and powers that I may acquire in the future. DISPATCH powers shall include, but not be limited to, the power to: • Professional dispatch services, including contact drivers, shippers and brokers on my behalf for cargo. Transfer of Paperwork (Carrier Packet, Rate Confirmations, Insurance Certificates, Invoices and all necessary Paperwork) to shippers. Sign and execute rate confirmations for freight and collect all payment dues on my behalf. This Power of Attorney shall be construed broadly as a health insurance policy, it may provide some coverage General Power of Attorney. The listing of specific powers is not intended to limit or restrict the general powers granted in this Power of Attorney in any manner. DISPATCH shall not be liable for mental health services. • Our office will obtain the necessary pre-authorization for services. You do not need to call do obtain authorizationany loss that results from a judgment error that was made in good faith. However, it DISPATCH shall be liable for willful misconduct or the failure to act in good faith, while acting under the authority of this Power of Attorney. I authorize DISPATCH to indemnify and hold harmless any third party who accepts and acts under this document. This Power of Attorney shall become effective immediately and shall remain in full force and effect until revoked in writing. Such revocation is helpful to find out exactly what mental health benefits you be send via e-mail 10 days in advance to DISPATCH to XxxxXxxxXxxxxxxx0@xxxxx.xxx IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date below. SIGNATURE SIGNATURE TITLE PRESIDENT / CEO DATE / / DATE / / Dispatch + Carrier = Agreement Initials MDH _ / _ _ Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. 1 Name (as shown on your income tax return). Name is required on this line; do have such as your specialist copaynot leave this line blank. 2 Business name/disregarded entity name, deductibles, maximum number if different from above 3 Check appropriate box for federal tax classification; check only one of appointments per year, exclusionary diagnoses, etc. • You are responsible for paying your copay, cothe following seven boxes: Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate single-insurance and amounts applied to your deductible. There are occasions when we are misquoted by insurance companies. You are responsible for understanding your policy and paying the difference if we are misquoted by your insurance member LLC Limited liability company. • If services are denied by your insurance company Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for any reason, you are responsible for covering the full cost tax classification of the service renderedsingle-member owner. • Always check your Explanation of Benefits 4 Exemptions (EOBcodes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) Other (see instructions) a (Applies to make sure that you are paying accounts maintained outside the correct copay or co-insurance amountU.S.) 5 Address (number, street, and that you satisfy your deductible, if applicableapt. You will likely receive your EOB before we receive a copy. If there is a difference, please let us know as soon as possible so we can remedy the situation. Patient refunds are typically conducted on a quarterly basis, unless otherwise requested. • If you have a deductible, it is your responsibility to keep up with it being met; as we do not have access to other providers you have seen. Please remember that deductibles are typically based on when claims are submitted not when the service was rendered. • If your child is seeing another mental health provider, please contact your insurance company to determine if your child can be treated by two mental health providers at the same time. Most policies do not allow a child to have two psychologists or mental health counselors at the same time suite no.) Requester’s name and you may have to cancel an existing authorization for the new provider to be covered. In some cases, insurance may also not cover psychiatry visits if seen on the same day as we provide services, depending on which codes your psychiatrist bills. In such instances, you may have to choose between the two providers, or pay out of pocket for the service not covered under the insurance policy. • There are also situations in which insurance will deny coverage if your child has a pre-existing condition. This typically occurs when you have switched insurance carriers and not reported a mental health diagnosis. Please check your benefits to make sure there is not a waiting period for your mental health benefits to begin. We are not told up front if you have an exclusionary pre-existing condition clause and you will be responsible for payment if services are denied. • If your insurance carrier changes please let us know as soon as possible, before your child’s next appointment. We make every effort to obtain your insurance authorization and benefits before your appointment. If authorization is not obtained before the appointment, the appointment may not be covered and you may be responsible for payment. • You should also be aware that your contract with your insurance company requires that we provide information relevant to the services that we provide to you. We are required to provide a clinical diagnosis.address (optional)

Insurance Information. If you have a health insurance policy, it may provide some coverage for mental health services. • Our office will obtain the necessary pre-authorization for services. You do not need to call do obtain authorization. However, it is helpful to find out exactly what mental health benefits you do have such as your specialist copay, deductibles, maximum number of appointments per year, exclusionary diagnoses, etc. • You are responsible for paying your copay, co-insurance and amounts applied to your deductible. There are occasions when we are misquoted by insurance companies. You are responsible for understanding your policy and paying the difference if we are misquoted by your insurance company. • If services are denied by your insurance company for any reason, you are responsible for covering the full cost of the service rendered. • Always check your Explanation of Benefits (EOB) to make sure that you are paying the correct copay or co-insurance amount, and that you satisfy your deductible, if applicable. You will likely receive your EOB before we receive a copy. If there is a difference, please let us know as soon as possible so we can remedy the situation. Patient refunds are typically conducted on a quarterly basis, unless otherwise requested. • If you have a deductible, it is your responsibility to keep up with it being met; , as we do not have access to other providers you have seen. Please remember that deductibles are typically based on when claims are submitted not when the service was rendered. • If your child is seeing another mental health provider, please contact your insurance company to determine if your child can be treated by two mental health providers at the same time. Most policies do not allow a child to have two psychologists or mental health counselors at the same time and you may have to cancel an existing authorization for the new provider to be covered. In some cases, insurance may also not cover psychiatry visits if seen on the same day as we provide services, depending on which codes your psychiatrist bills. In such instances, you may have to choose between the two providers, or pay out of pocket for the service not covered under the insurance policy. • There are also situations in which insurance will deny coverage if your child has a pre-existing condition. This typically occurs when you have switched insurance carriers and not reported a mental health diagnosis. Please check your benefits to make sure there is not a waiting period for your mental health benefits to begin. We are not told up front if you have an exclusionary pre-existing condition clause and you will be responsible for payment if services are denied. • If your insurance carrier changes please let us know as soon as possible, before your child’s next appointment. We make every effort to obtain your insurance authorization and benefits before your appointment. If authorization is not obtained before the appointment, the appointment may not be covered and you may be responsible for payment. • You should also be aware that your contract with your insurance company requires that we provide information relevant to the services that we provide to you. We are required to provide a clinical diagnosis.