ASSIGNMENT OF INSURANCE BENEFITS & VERIFICATION ACKNOWLEDGMENT
I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage or payment by my insurance company, and that I am financially responsible for all services rendered to me by ORA. I hereby understand, acknowledge and agree that ORA will bill any insurance provider I so designate on my the Insurance Verification form; however, if for any reason, such third party payor refused to pay all or part of the amount owed, I agree that I will be financially responsible for any unpaid amounts, including, but not limited to co-payments, co-insurance, deductibles and non-covered products or services. I also understand that all out-of-network (non-contracted) insurance billing services provided by ORA on my behalf are performed on a courtesy basis and can be discontinued by either myself or ORA, with written notice, at any time. I consent to the release of all protected health information by ORA and its agents for the purposes of healthcare management and/or for processing of medical claims and/or payment. I agree that I will notify ORA immediately of any changes in my insurance coverage or insurance provider(s). I acknowledge and agree that I have received a Notice of Privacy Practices.