Assignment of Benefits
Path CCM Assignment of Benefits Form
Path CCM, Inc. provides management and administrative support services to SUD Specialty Group – CA, Mental Health Specialty Group, p.c., and Mental Health Specialty Group NJ, p.a. (collectively, “Group”). This form applies to Path CCM and its medical group affiliates listed above.
I hereby assign to the “Group” all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any insurance payer, including Medicare, private insurance and any other health plan for medical treatment rendered by the “Group.” The assignment will remain intact until revoked by me in writing. I authorize the release of pertinent information necessary to process my medical claim. I also authorize direct payment to the “Group” of all insurance benefits payable to me for such medical treatment. In the event an insurance payer pays me directly, I agree to immediately pay such amounts to the “Group.”.
The “Group’s” quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. We suggest to all patients that they contact their insurance to confirm their benefits.
Under this arrangement, I am responsible for paying my copay, any non-covered portions, and any deductible I have yet to cover. In addition, if my insurance company does not pay for our services, I agree to pay for the services provided by Group.
Group’s quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.
I understand that my insurance payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying the “Group” for any and all amounts not paid by my insurance payer, including non-covered charges (in accordance with an applicable financial responsibility agreement) and all copayments and deductibles. I understand that if my insurance requires a referral, I am responsible for obtaining one prior to my appointment. In the event any collection action is necessary to collect amounts I owe to the “Group”, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.
I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.
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