Common Contracts
2 similar Authorization Agreement contracts
ContractAuthorization Agreement • February 3rd, 2024
Terms of Agreement: I hereby authorize Miracle Family Speech Therapy (MFST) to submit a claim to my insurance carrier for all covered services rendered by the therapist and authorize and direct my insurance carrier or its intermediaries to issue payment checks directly to the therapist rendering the covered service. I will be responsible for those charges deemed not covered by said insurance carrier so long as such insurance has not been deemed such services to be medically inappropriate or unnecessary. I also understand that if my insurance company is not a contracted carrier, I am responsible for the full fee charged by my therapist regardless of what my insurance pays. I authorize MFST to furnish complete information to my insurance carrier and its intermediaries regarding the services rendered. I permit a copy of this authorization to be used in the place of the original. I consent to assign all payments for these services to this practice. I understand that I am responsible for al
ContractAuthorization Agreement • October 5th, 2020
Terms of Agreement: I hereby authorize Miracle Family Speech Therapy (MFST) to submit a claim to my insurance carrier for all covered services rendered by the therapist and authorize and direct my insurance carrier or its intermediaries to issue payment checks directly to the therapist rendering the covered service. I will be responsible for those charges deemed not covered by said insurance carrier so long as such insurance has not been deemed such services to be medically inappropriate or unnecessary. I also understand that if my insurance company is not a contracted carrier, I am responsible for the full fee charged by my therapist regardless of what my insurance pays. I authorize MFST to furnish complete information to my insurance carrier and its intermediaries regarding the services rendered. I permit a copy of this authorization to be used in the place of the original. I consent to assign all payments for these services to this practice. I understand that I am responsible for al
