Authorization to charge my Credit Card
I hereby authorize Eastern Maternity (EM) to authorize my credit card. If I have health insurance that covers the items I have selected the authorization will be released within 7 days. If my insurance is not valid or denies the claims not because of Eastern Maternity fault I authorize to be charged for the retail cost of these items.
Assignment of Benefits
I hereby assign all medical and durable medical equipment benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), private insurance, and any other health/medical plan, to issue payment check(s) directly
to Nationwide Sleep Therapy, LLC or Eastern Pulmonary Services, Inc d/b/a Eastern Maternity and for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. I furthermore understand that I am waiving any anti-assignment clauses that are written into my health care contract. I have requested that the office of EM be my agent in the filing, processing, and appealing of claims related specifically to medical treatment rendered by this office. I understand that I have the opportunity to submit my bills directly to my health insurance carrier but have chosen voluntarily to have the claims submitted by and paid directly to the office of EM with an accompanying explanation of benefits.
I authorize Eastern Maternity to execute transactions on the above account. I consent to the use of the above payment method without my signature on the individual transactions in satisfying my obligations to EM I understand that an electronic copy of this agreement will serve as an original, and this payment authorization cannot be revoked.