Common use of Reimbursement Clause in Contracts

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third third-party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare dental services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare dental services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical dental expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare dental services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare dental services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare dental services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare dental services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare dental services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare dental services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, If we also have reimbursement rights. If give you recover benefits or make payment for services under this agreement and you get money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services those services, you must pay us back. This is true even if you receive the money after a settlement or a judgment. For example, if your auto insurance pays for your emergency room visit after a car accident, you must reimburse us for any benefit payment that we provided under this plan, as described in the subrogation section abovemade. We can seek from collect the money no matter where it is or how it is designated. You must pay us back even if you reimbursement up to do not get back the total amount of any payment made to you, whether • all or part of your claim against the payment to third party. We can collect the money you was designated, allocated, or characterized receive even if it is described as a payment for medical something other than health care expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan agreement until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will payparty. If we must pay legal fees in order to recover money from you, we can recover those these costs from you as wellyou. The Also, the amount that you must pay us cannot be reduced by any legal costs that you have paidhave. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, us quickly so we can respond in court. You further agree: • must give us information and help us. This means you must complete and sign all necessary documents to notify help us promptly and get money back. You must tell us in writing when notice is given to any third party or representative a timely manner about the progress of a third party of the intention to investigate or pursue a your claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up This includes filing a claim or lawsuit, beginning settlement discussions, or agreeing to the cost of the covered healthcare services; • to a settlement in principle, etc. It also means that you must give us a first priority lien on timely notice before you settle any recovery, settlement, or judgment or other source of compensation which may be had by any third partyclaim. You agree to must not do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice anything that might limit our rights as set forth aboveunder this Section. This includes, but is not limited to, refraining from making We may take any settlement or recovery which specifically attempts action necessary to reduce or exclude the full cost protect our right of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repaymentsubrogation and/or reimbursement.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether •  all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or •  the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: •  to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; •  to cooperate with us and provide us with requested information; •  to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; •  to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; •  to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; •  to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; •  to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; •  that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; •  that no court costs or attorney fees may be deducted from our recovery; •  that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and •  that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, If we also have reimbursement rights. If give you recover benefits or make payment for services under this agreement and you get money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services those services, you must pay us back. This is true even if you receive the money after a settlement or a judgment. For example, if your auto insurance pays for your emergency room visit after a car accident, you must reimburse us for any benefit payment that we provided under this plan, as described in the subrogation section abovemade. We can seek from collect the money no matter where it is or how it is designated. You must pay us back even if you reimbursement up to do not get back the total amount of any payment made to you, whether • all or part of your claim against the payment to third party. We can collect the money you was designated, allocated, or characterized receive even if it is described as a payment for medical something other than health care expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan agreement until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will payparty. If we must pay legal fees in order to recover money from you, we can recover those these costs from you as wellyou. The Also, the amount that you must pay us cannot be reduced by any legal costs that you have paidhave. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, us quickly so we can respond in court. You further agree: • must give us information and help us. This means you must complete and sign all necessary documents to notify help us promptly and get money back. You must tell us in writing when notice is given to any third party or representative a timely manner about the progress of a third party of the intention to investigate or pursue a your claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up This includes filing a claim or lawsuit, beginning settlement discussions, or agreeing to the cost of the covered healthcare services; • to a settlement in principle, etc. It also means that you must give us a first priority lien on timely notice before you settle any recovery, settlement, or judgment or other source of compensation which may be had by any third partyclaim. You agree to must not do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice anything that might limit our rights as set forth aboveunder this Section. This includes, but is not limited to, refraining from making We may take any settlement or recovery which specifically attempts action necessary to reduce or exclude the full cost protect our right of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; subrogation and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repaymentreimbursement.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third third-party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether •  all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or •  the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: •  to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; •  to cooperate with us and provide us with requested information; •  to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; •  to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; •  to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; •  to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; •  to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; •  that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; •  that no court costs or attorney fees may be deducted from our recovery; •  that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and •  that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether •  all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or •  the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: •  to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; •  to cooperate with us and provide us with requested information; •  to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; •  to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; •  to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; •  to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; •  to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; •  that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; •  that no court costs or attorney fees may be deducted from our recovery; •  that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and •  that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare dental services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare dental services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether •  all or part of the payment to you was designated, allocated, or characterized as payment for medical dental expenses; or •  the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare dental services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: •  to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; •  to cooperate with us and provide us with requested information; •  to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; •  to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare dental services; •  to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare dental services associated with third party responsibility; •  to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare dental services provided by this plan; •  to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; •  that we may recover the full cost of the covered healthcare dental services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; •  that no court costs or attorney fees may be deducted from our recovery; •  that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and •  that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare dental services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition to the subrogation rights described above, we also have reimbursement rights. If you recover money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under this plan, as described in the subrogation section above. We can seek from you reimbursement up to the amount of any payment made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will pay. If we pay legal fees to recover money from you, we can recover those costs from you as well. The amount you must pay us cannot be reduced by any legal costs you have paid. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your partparty, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorneyatto rney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repayment.

Reimbursement. In addition If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to the subrogation rights described abovewhich you are entitled; however, we also have reimbursement rightsyou (not your insurance company) are responsible for full payment of my fees. If you recover money by lawsuithave questions about the coverage, settlementcall your insurance plan administrator. You should also be aware that your contract with your health insurance company (or, in some cases, a non- profit organization or individual making payments on your behalf) requires that I provide it with information relevant to the services that I provide to you, if you want them to reimburse you for services I provide. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or otherwisecopies of your entire clinical record. In such situations, we I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it. In some cases, they may seek reimbursement from share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your insurance carrier or organization/individual making payments on your behalf. Signed Date This agreement contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosures of your Protected Health Information (PHI) used for covered healthcare services for the purpose of treatment, payment, and health care operations. The Notice of Policies and Practices to Protect the Privacy of Your Health Information (NOTICE), which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services we provided under accompanies this plan, as described agreement and is available in the subrogation section abovewaiting room, explains HIPAA and its application to our personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although the NOTICE is long and sometimes complex, it is very important that you read it carefully before our next session. We can seek from discuss any questions you reimbursement up have about the procedures at that time. When you sign this document, it becomes an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to the amount of any payment process or substantiate claims made to you, whether • all or part of the payment to you was designated, allocated, or characterized as payment for medical expensesunder your policy; or • if you have not satisfied any financial obligations you have incurred. Psychotherapy may involve a variety of activities designed to support you in successfully resolving the payment difficulties or conditions which have led you to seek therapy. It is for an amount less than that necessary to compensate a learning process; learning about yourself, understanding feelings and behavior and accepting and valuing yourself. Your therapy will be most successful if you fully for the illness or injury. We may offset future payments under this plan until we have been paid an amount equal to engage openly and honestly in it, and apply what you were paid by a third party for the cost are discovering to how you live your life. Psychotherapy can have risks as well as benefits. Since therapy often involves exploring unpleasant aspects of the covered healthcare services that we paid life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. These feelings (and others which you may dislike) are often an essential element in successful therapy; such therapy can lead to better relationships, solutions to specific problems and significant increases in one's well being. Our first session or two will pay. If we pay legal fees involve an exploration of your needs, after which I will be able to recover money from you, suggest some basic issues and ways we can recover those costs from you as welladdress them. The amount you must pay us cannot be reduced by any legal costs you have paidYou should consider this information along with your own opinions in choosing whether to work with me. If you receive money in a settlement have questions about my approach or a judgment and do not agree with our right to reimbursementother relevant matters, you must keep an amount equal to our claim in a separate account until the dispute is resolvedplease bring them up as they arise. If your reservations or objections persist, I will help you set up a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, so we can respond in court. You further agree: • to notify us promptly and in writing when notice is given to any third party or representative of meeting with another mental health professional for a third party of the intention to investigate or pursue a claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up to the cost of the covered healthcare services; • to give us a first priority lien on any recovery, settlement, or judgment or other source of compensation which may be had by any third party. You agree to do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice our rights as set forth above. This includes, but is not limited to, refraining from making any settlement or recovery which specifically attempts to reduce or exclude the full cost of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs and attorney fees incurred by this plan in obtaining repaymentsecond opinion.

Reimbursement. In addition to the subrogation rights described above, If we also have reimbursement rights. If give you recover benefits or make payment for services under this agreement and you get money by lawsuit, settlement, or otherwise, we may seek reimbursement from you for covered healthcare services for which we paid or will pay. Our reimbursement right applies when you received payment from a third party for covered healthcare services those services, you must pay us back. This is true even if you receive the money after a settlement or a judgment. For example, if your auto insurance pays for your emergency room visit after a car accident, you must reimburse us for any benefit payment that we provided under this plan, as described in the subrogation section abovemade. We can seek from collect the money no matter where it is or how it is designated. You must pay us back even if you reimbursement up to do not get back the total amount of any payment made to you, whether • all or part of your claim against the payment to third party. We can collect the money you was designated, allocated, or characterized receive even if it is described as a payment for medical something other than health care expenses; or • the payment is for an amount less than that necessary to compensate you fully for the illness or injury. We may offset future payments under this plan agreement until we have been paid an amount equal to what you were paid by a third party for the cost of the covered healthcare services that we paid or will payparty. If we must pay legal fees in order to recover money from you, we can recover those these costs from you as wellyou. The Also, the amount that you must pay us cannot be reduced by any legal costs that you have paidhave. If you receive money in a settlement or a judgment and do not agree with our right to reimbursement, you must keep an amount equal to our claim in a separate account until the dispute is resolved. If a court orders that money be paid to you or any third party before your lawsuit is resolved, you must tell us, at that time, us quickly so we can respond in court. You further agree: • must give us information and help us. This means you must complete and sign all necessary documents to notify help us promptly and get money back. You must tell us in writing when notice is given to any third party or representative a timely manner about the progress of a third party of the intention to investigate or pursue a your claim to recover damages or obtain compensation; • to cooperate with us and provide us with requested information; • to do whatever is necessary to secure our rights of subrogation and reimbursement under this plan; • to assign us any benefits you may be entitled to receive from a third party. Your assignment is up This includes filing a claim or lawsuit, beginning settlement discussions, or agreeing to the cost of the covered healthcare services; • to a settlement in principle, etc. It also means that you must give us a first priority lien on timely notice before you settle any recovery, settlement, or judgment or other source of compensation which may be had by any third partyclaim. You agree to must not do this to the extent of the full cost of all covered healthcare services associated with third party responsibility; • to do nothing to prejudice anything that might limit our rights as set forth aboveunder this Section. This includes, but is not limited to, refraining from making We may take any settlement or recovery which specifically attempts action necessary to reduce or exclude the full cost protect our right of the covered healthcare services provided by this plan; • to serve as a constructive trustee for the benefit of this plan over any settlement or recovery funds received as a result of third party responsibility; • that we may recover the full cost of the covered healthcare services provided by this plan without regard to any claim of fault on your part, whether by comparative negligence or otherwise; • that no court costs or attorney fees may be deducted from our recovery; • that we are not required to pay or contribute to paying court costs or attorney’s fees for the attorney hired by you to pursue your claim or lawsuit against any third party; subrogation and • that in the event you or your representative fails to cooperate with us, you shall be responsible for all costs associated with covered healthcare services provided by this plan, in addition to costs reimbursement. Appeal DIR DEN (09-10) How To File and attorney fees incurred by this plan in obtaining repayment.Appeal A Claim 28