Disclosures

Financial Responsibility
I have requested professional services from AAA DME LLC DBA Music City Med LLC on behalf of myself and/or my dependents, and understand that bymaking this request; I am responsible for all charges incurred during the course of said services. I understand that all fees for said services are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate
statement unless other arrangements have been made in advance.

Assignment of Insurance Benefits
I hereby assign all applicable health insurance benefits to which I and/or my dependents are
entitled to AAA DME LLC DBA Music City Med LLC I certify that the health insurance information that I provided
to AAA DME LLC DBA Music City Med LLC is accurate as of the date set forth below and that I am responsible for keeping it updated.I hereby authorize AAA DME LLC DBA Music City Med LLC LLC. To submit claims, on my and/or my dependent’s behalf,
to the benefit plan (or its administrator) listed on the current insurance card I provided to AAA DME LLC DBA Music City Med LLC in good faith. I also hereby instruct my benefit plan (or its administrator) to pay AAA DME LLC DBA Music City Med LLC directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to AAA DME LLC DBA Music City Med LLC, I hereby instruct and
direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and AAA DME LLC DBA Music City Med LLC upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make the check payable to me and mail it directly to AAA DME LLC DBA Music City Med LLC - 810 Dominican Drive, Nashville, TN, 37228.I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from AAA DME LLC DBA Music City Med LLC are paid in full. I also
understand that I am responsible for all amounts not covered by my health insurance, including
co-payments, co-insurance, and deductibles.

 

 

Disclosures

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.

ERISA Authorization
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