I hereby instruct the above-named insurance company/companies to pay by check made out to and mailed directly to:
Therapeutic Evolution Physical Therapy (Assignee) for professional or medical expenses allowable and otherwise payable to me
under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT
ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-
mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services
and/or fees, over and above the insurance payment or as required by my insurance policy.
I hereby release Assignee, its officers, agents, employees and any clinical staff associated with my case, from all liability that may
arise as a result of disclosure of information to the above-named insurance company(s) or their designated representatives. By
signing this Assignment of Benefits and Release of Medical Information I acknowledge the following: I am aware and understand
that this authorization will not be used unless the above named insurance company(s) or their designated representatives request
records of information for reimbursement purposes; or seek to take action reference payment for treatment services, I agree to
participate and assist Assignee or its designated representatives with any appeal process necessary to collect payments for services
rendered, I understand that this assignment and authorization is subject to revocation at any time except to the extent that action
has been taken in reliance thereof, I understand Assignee is acting in filing for insurance benefits assigned to myself and it can
assume no responsibility for guaranteeing payment of any charges from the insurance company(s), I understand a firm contracted by
Assignee for billing and collection purposes may do billing, I understand that Assignee is appointed by me to act as my
representative and on my behalf in any proceeding that may be necessary to seek payment from my insurance carrier which
includes receiving a copy of my insurance plan’s documents, I agree that should an overpayment take place, a refund check will be
mailed to the authorized party that is due the overpayment, I agree that Assignee shall be entitled to the full amount of its charges
without offset.
HIPAA REGULATIONS
I understand that Therapeutic Evolution Physical Therapy complies with HIPAA and will protect my Protected Health Information
(PHI) and will use it as allowable by law in the treatment, billing and collection pertaining to my care until my case is closed and full
payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or
attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to
effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.