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  • 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.

  • Personal Health Information Disclosure and Use (PHI) / Patient Privacy - Express Relief, LLC
    Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

    • Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.
    • Payment - Your PHI may be used and disclosed for submission of your claim to your insurance carrier for payment and / or your legal representative for payment or by any of your legal representative's requests.
    • Care Operations - Your PHI may be used and disclosed to staff members for the purpose of providing service.
    • As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.
    • Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.
    • Appointment Reminder - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.
    • Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.
    • Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.
    • With limited exceptions, you can make a written request to inspect your PHI that is maintained by us for our use. Your PHI includes basic information about your diagnosis, treatment dates, treatment plans, intake and termination summaries.
    • Requested copies of any PHI information will be provided per request in conjuction with local, state and Federal rules and regulations.
    • You must make a written request to have your PHI communicated with you by alternative means at an alternative location. (An example would be if your primary language is not spoken and a child for whom you have lawful custody is being treated.) Your written request must specify the alternative means and location.
    • You can make a written request that restrictions be placed on other ways we use or disclose your health information. Any or all of your requested restrictions may be denied. If these restrictions are agreed to, they will be abided by in all situations except those in which professional judgment constitutes an emergency.
    • You can make a written request that your PHI be amended.
    If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing.
    If denied, you can place a written statement in your records disagreeing with the denial of your request.

  • Express Relief, LLC and Express Relief Healthcare Network, its agents, affiliates, employees, contractors, representatives and the healthcare providers (Express Relief) thank you for visiting our Website and App (Website"). The following Website Terms of Use Agreement (the "Agreement") governs your use of the Website.
    PLEASE READ THESE TERMS OF USE CAREFULLY BEFORE USING THIS APP AND WEBSITE. By using this App and Website you agree to this Terms of Use Agreement. If you do not agree to these Terms of Use and the privacy policy please exit and disregard the information contained herein.
    Electronic Signature
    Those who want to sign on paper, then print and sign the PDF version at under "Print Form", complete it, sigh it, and fax it immediately to the number indicated on the App and Website and/or form. You affirmatively consent to the use of this electronic signature and have not withdrawn such consent, prior to consenting you:
    1. I understand that I have the right or option to have this record provided or made available on paper or in non-electronic form (this form is available for you to print or we can mail you a copy on your request, a printable format is available on our web site at 2. Have the right to withdraw this consent to have the record provided or made available in an electronic form and of any conditions, consequences ( which may include termination of both parties' relationship) or fees in the event of such withdrawal 3. If you wish to withdraw this consent, please e-mail us at 4. We may contact you via telephone, e-mail, US mail or other delivery method in order to update your electronic communication information in compliance with Federal guidelines, statutes and law. 5. After such consent, you may upon request, obtain a paper copy of an electronic record free of charge by printing this form on your computer or by requesting it from us. 6. Prior to consenting you understand that the hardware and software requirements to access and retain this electronic record is any computer which can access the internet and has a compatible web browser. 7. This electronic consent or electronic confirmation demonstrates that you can access information in the electronic Authorization form. 8. After such consent, if there is a change in the hardware or software requirements needed to access or retain electronic records creates a material risk that the you will not be able to access or retain a subsequent electronic record that was the subject of the consent, Express Relief provides the following: (i) provides you with a statement of (I) the revised hardware and software requirements for access to and retention of the electronic records, and (II) the right to withdraw consent without the imposition of any fees for such withdrawal and without the imposition of any condition or consequence that was not disclosed under these disclosures.
    You are required to comply with all applicable laws in connection with your use of the App and Website, and such further limitations as may be set forth in any written or on-screen notice from Express Relief . As a condition of your use of the Website, you agree that you will not use the Website for any purpose that is unlawful or prohibited by this Agreement.
    You agree and consent to the terms of the Express Relief privacy policy which is available from Express Relief.
    When you visit the Website, telephone Express Relief or send e-mail(s) to Express Relief you are communicating with Express Relief electronically or telephonically. You consent to receive communications from Express Relief electronically or telephonically. Express Relief may communicate with you by e-mail or telephonically. You agree that all agreements, notices, disclosures and other communications we provide to you electronically or telephonically satisfy any legal requirement that such communications be in writing.
    You agree and consent to the following: Express Relief provides a healthcare provider platform which facilitates app, email, web and telephonic communications between healthcare providers and healthcare patients in the states where applicable as well as billing services for the healthcare providers . Express Relief, LLCl and Express Relief Healthcare Network are not responsible for any actions, and/or medical advice provided by any healthcare providers. Express Relief gives no medical advice whatsoever. All healthcare providers are not employees and are private contractors. In good and valuable consideration for the use of the app, App and Website, communication portal, payment and billing system and/or any other functionality or service provided by Express Relief, I hereby indemnify and hold harmless Express Relief, LLC, Express Relief Healthcare Network, and its employees, affiliates, affiliate organizations, contractors, agents, representatives and its assignees harmless from any and all actions taken or not taken by the Provider(s) and for any and all medical services, medical care, medical advice, medical decisions, prescriptions, nurses orders, physician orders, failures, inaccuracies, malfunctions, and/or delays in scheduling, electronic medical records software and systems, teleconferencing software and systems and/or videoconferencing software and systems, and billing and payment processing software and systems. I hereby release Express Relief, LLC and Express Relief Healthcare Network, LLC and it employees, agents, affiliates, employees, contractors, and assignees from any and all actions in regard to my medical care and from the use of any and all software and systems on this App and Website and used by the Provider(s) during my medical care.
    The healthcare providers in the network have promised to adhere to all scheduling requests within an hour and see a patient online video conferencing or telephonically. If a network provider does not comply, the App and Website user agrees to indemnifies and hold harmless Express Relief from the tardiness of a network provider. Each healthcare provider carries their own liability insurance. Express Relief is not responsible for missed or late appointments from the provider(s).By using this site, the user shall not hold Express Relief liable for any actions made or not made by the healthcare providers. The user of this site agrees never to use this site in an emergency situation. This site is not for emergency use. Always call 911 in an emergency. Seek emergency help immediately
    I consent to this online video visit delivered through the app and/or website. By signing my name below I am consenting to treatment delivered through Express Relief online video and/or telephonic conferencing and that I agree with the above Terms and Conditions, Service, Electronic Signature & Consent to Video Visit.

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