WOMEN'S HEALTH SURGICAL CENTER Appointment of Administrative Representative; Assignment of Benefits and Rights; Assignment of Causes of Action; and Authorization to Release Information
APPOINTMENT OF REPRESENTIVE:
The undersigned hereby appoints WOMENS HEALTH SURGICAL CENTER (herein “WHSC”), or its assignee, as my duly authorized representative and assignee during any: (1) Administrative claims process; (2) Appeal or Review process for a denied or underpaid claim; or (3) State or Federal legal process, necessary to collect claims submitted on my behalf for health insurance benefits, but denied or underpaid by my plan. The CLAIMS ADMINISTRATOR, PLAN ADMINISTATOR or GROUP INSURANCE ADMINSTRATOR for my medical insurance plan are all hereby notified and directed by me to henceforth regard any and all communications, particularly including all requests for information, received from my representative during the administrative process, as though these communications had been received from me. I understand that the United States Department of Labor has published the national minimum standards for the administrative processing review of claims, found at 29 CPR 2560.503-1. I ask all administrators to abide by these minimum standards. I demand complete and timely disclosure to my representative of (a) All pertinent documents, including the identity of their signatory or authors, and (b) The identity of any person or entity possessing the discretion to approve or deny my claim. In addition, I demand compliance with applicable California enactments regarding full and fair review of claims.
BUSINESS PURPOSE AND RIGHT TO RECEIVE BENEFITS:
The duly authorized representative and assignee named above in (1) is Authorized to directly receive payment for the medical benefits due to me, under my insurance or plan. This assignment of benefits by me is complete. I retain no interest in the benefits due to me under these claims for medical care and facility fees. This assignment is given by me in return for the medical care and related services I have received or will receive, from the health providers associated with my representative and assignee. I understand that if my claims are denied and the denial is upheld, I remain financially responsible for payment of all charges incurred to the extent allowed by law. Additionally, regardless of my insurance benefits, if any, I understand I am financially responsible for the fees for the services rendered to the extent allowed by law. I understand that my assignment of these rights and my appointment of an administrative representative serves a valid business purpose. The purpose is to provide an effective mechanism for my doctors and other health care providers to deal with an administrative or legal process that may be necessary to collect the benefits due for the services provided. The medical and business
purpose, my assignee is not necessarily my health care provider for assignments created under federal law in MISIC v. BUILDING SERVICE HEALTH 789 F2D 1372 (9th CIR. 1986). In furtherance of this business purpose, my assignee is not necessarily my health care provider for any specific claim, but is rather the individual(s), organization, group and/or corporation designated by my providers to deal with all administrative and legal matters.
If my claim for benefits is administratively denied in whole or in part, I hereby assign ALL causes of action for judicial review to the individual(s), organization, group and/or corporation designated in (1). My assignee may ‘STAND IN MY SHOES”, as that phrase is understood under assignment law. I intend my personal standing under the ERISA civil enforcement procedures (codified at 29 U.S.C. 1132) to be transferred to my assignee, so that he, she, they or it may seek judicial review of benefits claim denies, under I 132(a)(l)(B). My assignment also includes my right to seek review as a “claimant”, under 1132(c), of any administrator’s refusal or failure to provide information, 30 days after a written request.
RELEASE OF INFORMATION:
I also authorize release of information and payment of medical benefits to the physician or supplier for services described. I certify that the information given by me in the applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf.
DIRECT PAYMENT BY INSURANCE TO PATIENT:
If my insurance company pays me directly for services performed by WHSC it is understood that I will promptly bring such payment and/or check directly to PRC and endorse such check and/or payment directly WHSC, or immediately issue WHSC a personal check for same amount.
a monthly finance charge of 1.5% (18% per annum) may be assessed on any unpaid balances due. This applies to any balance that is determined to be responsibility of patient and/or guarantor.
Patient/Assignor Printed Name
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