ASSIGNMENT OF BENEFITS I hereby assign and authorize payment directly to Pediatric Associates of Kingston, LLC (“Pediatric Associates”), and to any physician employed by or contracted with Pediatric Associates, all insurance benefits, sick benefits, injury benefits due because of liability of a third-party, or proceeds of all claims resulting from the liability of a third party, payable by any party, organization, et cetera, to or for the pediatric patient and the NEPA Breastfeeding Center patient, as applicable. If pediatric patient and/or NEPA Breastfeeding Center patient is eligible for Medicaid, I have requested Medicaid services and benefits. I further agree that this assignment will not be withdrawn or voided at any time until the pediatric patient’s and/or the Breastfeeding Center of NEPA patient’s account is paid in full.
I understand that I may be responsible for payment in full of any amount due that is not covered or paid for by my insurance policy, benefit plan, or other payor. I understand that in this case, I am obligated to pay Pediatric Associates in accordance with its regular rates and terms. If I fail to make payment when due and the account becomes delinquent or is turned over to a collection agency or an attorney for collection, I agree to pay all collection agency fees, and associated court costs and attorney’s fees. I also agree that any patient or guarantor over payments may be applied directly to any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the over payment.
RELEASE OF INFORMATION AND STATEMENT OF ASSISTANCE
I authorize Pediatric Associates to furnish and release to my insurance carrier(s) or their representatives insuring the pediatric patient and/or the NEPA Breastfeeding Center patient any and all portions of the pediatric patient’s and the NEPA Breastfeeding Center patient’s medical records which may be necessary for completion of any claims for services, supplies, and equipment provided.
I consent for the Pediatric Associates and/or its attorneys to request, on my behalf, any information related to my health insurance policy (including, but not limited to, proof of insurance). This information may be given directly to Pediatric Associates and/or its attorneys.
I authorize Pediatric Associates to appeal on my behalf any denial for reimbursement, coverage, or payment for services or care provided to the pediatric patient and/or the NEPA Breastfeeding Center patient, as applicable. I agree to assist Pediatric Associates in collecting benefits that may be due or payable under my insurance policy for the services, supplies, and equipment provided.
I agree to provide Pediatric Associates and/or its attorneys with any additional information needed to process claims for payment. CONSENT FOR TREATMENT In this section, the term “patient” refers to the pediatric patient. The term “patients” refers to both the pediatric patient and the NEPA Breastfeeding Center patient, if applicable.
I hereby voluntarily authorize treatment of the patient or patients, as applicable, at Pediatric Associates.
I permit Pediatric Associates and its employees, physicians, fellows, residents, interns, and other qualified personnel involved in the patient’s or patients’ care to treat the patient or patients in ways they judge to be beneficial to the patient or patients.
I understand that I have the right to ask questions and to receive information about the patient’s or patients’ care and treatment, and the right to withdraw my consent for treatment or tests.
I understand that the results of any treatments, tests or care cannot be guaranteed. I also understand that I have the right to refuse any drugs, treatment, or procedures to the extent permitted by law for the patient or patients. I understand that medical, nursing, and other health care personnel in training may be observing and participating actively in the care of the patient or patients under the supervision of authorized personnel. I hereby give my consent to such observations and/or participation. I consent to the photographing, videotaping and/or video monitoring, including appropriate portions of the patient’s or patients’ body/ies, for medical and medical record documentation purposes, provided said photographs or videotapes are maintained and released in accordance with protected health information regulations.