Assignment of Insurance Benefits
By signing this document, I understand, request and authorize Express Relief,, LLC, the Express Relief Healthcare Network, its assignees, and/or its agents to bill for all online video visit(s), telephonic visit(s), all home therapy services, healthcare visits, diagnostic services and medical supplies provided to the insurance carrier and/or other payer. If medical supplies were ordered I also authorize Express Relief, LLC, Express Relief Healthcare Network, its assignees, and/or its agents to ship and supply the ordered supplies per the physician, nurse practitioner or healthcare provider’s recommendations and/or requested by me. I hereby authorize Express Relief, LLC, the Express Relief Healthcare Network, its assignees, and/or its agents to supply me with medical supplies as ordered. I also authorize Express Releif, LLC, the Express Relief Healthcare Network, its assignees, and/or its agents to bill and submit claims with the following codes: A4556 electrodes, A4557 lead wires, A4611 batteries, A4558 conductive gel, E0730, E0745, EO731 garment electrode, as well as other HCPCS/CPT codes that coincide with the directions of my physician or per my request, including codes for the instruction & use of the equipment. I understand that Express Releif, LLC the Express Releif Healthcare Network, its assignees, and/or its agents may use healthcare provider contractors and agents in order to fulfill such requests and requirements. I understand that some supplies may be reoccurring and will be billed and delivered every 2 months for at least 6 months in order to receive the greatest results, unless otherwise indicated by me or my physician. I can cancel the supplies at any time by faxed or email request. I understand that Express Relief, LLC is not covered under Medicare or any health insurance and will not submit any bill to these entities. I hereby understand that my assignment does not inculsde assignment for any federal, state or health care benefits.
I hereby authorize you, my insurance company and/or attorney, to pay directly Express Relief, LLC the Express Relief Healthcare Network, its assignees, and/or its agents (“Assignees”) such sums as may be due and owing to Assignees, and to withhold such sums for any medical payments, medpay benefits, No Fault benefits, or any other insurance benefits obligated to reimburse or form any settlement, judgment, or verdict on my behalf as may be necessary to adequately protect said Assignees, I hereby further give a lien to said Assignees any and all insurance benefits named herein and any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by Assignees. This is to act as an assignment of my right and benefits to extent of the Assignees supplies provided to me in accordance with state statute(s). I hereby grant the release to and from Express Relief, LLC, the Express Relief Healthcare Network, its assignees, and/or its agents of any/all medical records for the submission & processing of claims payment as well as the other valid uses acknowledged by me regarding my healthcare. In the event my insurance company obligated to make payments to me upon charges made by Assignees for supplies, refuses to make such payments, upon demand by me or Assignees, I hereby assign and transfer Assignees any and all causes of action that I might have or that exist in my favor against such company and authorize assignees to prosecute said causes of action either in my name or in Assignees’ name, and further I authorize Assignees to compromise, settle, or resolve said claim or cause of action as they see fit. In due, valid and good consideration for the free use of Express Relief website I hereby indemnify and hold harmless Express Relief, LLC the Express Relief Healthcare Network and its assignees, agents, employees, representatives and healthcare providers from any and all actions related to any and services or supplies given or not given and its billing of payer(s). To avoid exhaustion of insurance benefits while Assignees pursue its right under this assignment, I direct my insurance company to set aside and place in escrow any disputed amount or reductions until the resolution of such dispute. I authorize Assignees to release any information pertinent to my case to any insurance company, adjuster, or attorney to facilitate collection under this Assignment, Lien, and Authorization. I hereby understand and acknowledge that Assignees comply and make every effort to comply with all national, state and local privacy act regulations and requirements and a written copy will be furnished to me if I so request.