Assignment of Benefits/Rights to Health Insurance Payment,Patient Responsibility, Home Sleep Study Testing Policy and Release of Information Form
I, the undersigned, irrevocably assign to the provider/entity performing the healthcare services (“Provider”), [1]all of my rights and benefits and any other interests that I have in any health or medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services(each a “Plan”) in connection with medical services provided by Provider, its employees and agents. I understand that this document is a direct assignment of my rights and benefits under my Plan.
I instruct my insurance company to pay Provider directly for the professional or medical expense benefits payable to me. If my current policy prohibits direct payment to Provider, I instruct my Plan to make out the check to me and mail it directly to the Address referenced above for the professional or medical expense benefits payable to me under my Plan as payment towards the total charges for the services rendered. In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Provider will be immediately signed over and sent directly to Provider.
Patient Responsibility
I acknowledge and agree that I am responsible for all charges for services provided to me that are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent coverage is not available, or is limited, under my Plan, I acknowledge that I am responsible to Provider for all of theProvider’s charges for services furnished ,and I agree to pay Provider all charges not covered by my Plan. I agree to pay all bills within thirty days after receiving a statement or as otherwise expressly agreed.
Release of Information
I authorize Provider and/or its agents to release any medical or other information about me in its possession to my Plan, the Social Security Administration, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Provider.
A photocopy of this Assignment shall be considered as effective and valid as the original.
Home Sleep Study Testing Policy
Upon receiving my home sleep study, I agree to complete the test within 45 calendar days from date of delivery. If the sleep study is not completed within this time frame I will be charged full cash price of the home sleep test device and the interpretation. If after 45 calendar days I chooses not to complete the home sleep study, I may request a free return label from GEM. Upon receipt of the returned device I will not be charged and a claim for the home sleep study test will not be submitted to my insurance.
[1]For patients in FL and WI, this is known as “Gem Health Specialty Sleep Services, P.A.” For patients in CA, this is known as “Zinkel, M.D., P.C. ” For patients in MN, this is known as “Gem Health Specialty SleepServices of Minnesota, P.A.” For patients in NJ, this known as “Gem Health Specialty Sleep Services of New Jersey, P.C.” For patients in NY this is known as “Medical Telehealth Services of New York, P.C.” For patients in TX, this is known as “Gem Health Specialty Sleep Services of Texas, P.A.”
For patients in CO, this is known as “OpenLoop Healthcare Partners Colorado, PC”. For patients in WV, this is known as “OpenLoop Healthcare Partners, Inc.” For all other states not already mentioned, this is known as “Openloop Healthcare Partners, PC”.
