Authorization to Release Information
I hereby authorize AAA DME LLC DBA Music City Med LLC to: (1) release any information necessary to my health
benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance
claims generated in the
course of examination or treatment; and (3) allow a photocopy of my signature to be used to process
insurance claims. This order will remain in effect until revoked by me in writing.
I hereby designate, authorize, and convey to AAA DME LLC DBA Music City Med LLC LLC. To the full extent
permissible under law and under any applicable
insurance policy and/or employee health care benefit plan: (1) the right and ability to act on my
behalf in connection with any claim, right, or cause in action that I may have under such insurance
policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim,
right, or cause of action in connection with said insurance policy and/or benefit plan (including
but not limited to, the right to act on my behalf in respect to a benefit plan governed by the
provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare
expense incurred as a result of the services I received from AAA DME LLC DBA Music City Med LLC and, to the
extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement,
and any other applicable remedy, including fines.
A photocopy of this Assignment/Authorization shall be as effective and valid as the original.
Signature of Policyholder / Insured Date