Assignment of Benefits. By clicking where indicated, I, the undersigned, irrevocably assign to the Practice and Provider assigned to me by Midi Health, Inc. (collectively, “Provider”), all of my rights and benefits and any other interests that I have in any medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services (each a “Plan”) in connection with medical services provided by Provider, its employees and agents.
I understand that this document is a direct assignment of my rights and benefits under my Plan. I instruct my insurance company to pay Provider directly for the professional or medical expense benefits payable to me. If my current policy prohibits direct payment to Provider, I instruct my insurance company to make out the check to me and mail it directly to the address referenced below for the professional or medical expense benefits payable to me under my Plan as payment towards the total charges for the services rendered:
Midi Health, Inc.
445 S. Figueroa Street
Los Angeles, California 90071
In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Provider will be immediately signed over and sent directly to Provider.
Patient Responsibility. I acknowledge and agree that I am responsible for all charges for services provided to me which are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent no coverage exists under my Plan, I acknowledge that I am responsible for all charges for services provided and agree to pay all charges not covered by my Plan.
Release of Information. I authorize Provider and/or its agents to release any medical or other information about me in its possession to my Plan, the Social Security Administration, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Provider.
I acknowledge that my digital signature or other indication of acceptance of this Assignment shall be considered as effective and valid as an original signature.
Integrative Women's Care, P.C. and its affiliated entities Integrative Women’s Care P.C., IWC Medical Group, P.A., IWC Medical Group KS, P.A., and Robert G. Aptekar, M.D., P.C. , (collectively defined as “IWC”) is committed to providing the best quality healthcare services.
Patients Using Commercial Insurance
If you choose to use insurance for the payment of IWC services, and IWC is in-network for such insurance, by accepting this Agreement, you agree to allow IWC to disclose your information to the insurance plan you provided to IWC and any other health plan that pays for the cost of your medical or health care services now or in the future, for the purposes of IWC obtaining reimbursement for the services provided to you or otherwise communicating with the health plan regarding payment for services (this “Authorization”). This disclosure may include all health information pertaining to my medical history, mental or physical condition, and treatment and services received, including demographic information.
This Authorization is valid until you are no longer a patient of IWC, within five (5) years from the date indicated below, or applicable state law, whichever is earlier. You understand that you have the right to revoke this Authorization, in writing, at any time by sending such written notification to firstname.lastname@example.org.
Additionally, you agree to hereby assign IWC all right, title, and interest in any and all health insurance or other health care benefits payable to you or on my behalf by any in-network insurance payer for medical treatment rendered by IWC. You also authorize direct payment to IWC of all insurance benefits payable to you for such medical treatment. In the event an insurance payer pays you directly, you agree to immediately pay such amounts to IWC.
You understand that your insurance payer may pay less than the actual bill for services. You acknowledge that you are still responsible for paying IWC for any and all amounts not paid by the insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. You understand that if insurance requires a referral, you are responsible for obtaining one prior to an appointment. In the event any collection action is necessary to collect amounts you owe to IWC, you agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees. This assignment will remain in place until revoked by you.
You understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient of such information and may no longer be protected by federal or state law. However, state law may prohibit the person receiving my health information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law. IWC will not condition my treatment, payment, enrollment or eligibility for benefits on whether you provide authorization for the requested use or disclosure.
You understand that you have the right to: inspect or copy the protected medical information to be used or disclosed as permitted under federal or state law; refuse to agree to this Authorization; and receive a copy of this Authorization. You have read the above information and authorize the disclosure of my information by IWC or the purpose described herein.
Medicare, Medicaid and any Medicare-related Insurance
If you are enrolled in Medicare or Medicaid or any Medicare-related or Medicaid-related insurance programs (e.g. Medicare Advantage, MediCal, etc.), you agree that neither you, Midi, IWC, or any of the health care organization(s) or provider(s) with whom we partner to provide health care services to you will submit a claim for reimbursement to any of these insurance programs and/or carriers for the costs of the services and products provided to you related to our services. For example, if you are enrolled in Medicare and chose to see an IWC clinician on a self-pay basis, if you have labs or imaging completed related to our care, then you agree that you will not submit a claim to Medicare for reimbursement for any of the expense for the visit, the labs or imaging.
As further described above, we participate in certain PPO insurance plans (see https://www.joinmidi.com/pricing-insurance for active participating plans. Except for those active participating plans listed at https://www.joinmidi.com/pricing-insurance, We do not participate in any other commercial insurance plans and we do NOT participate in Medicare or Medicaid. Except as further described herein, our services are 100% self-pay by our patients. By signing this form, you acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance that is not listed on https://www.joinmidi.com/pricing-insurance and you do not want to use any insurance benefit for IWC services and acknowledge that IWC does not accept your health insurance.
In the event you have selected services for purchase from us on a self-pay basis, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. If, though you have selected our “self-pay” option, you intend to submit a claim to your insurance company, please note that your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider.There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.
IWC has provided you with the charges, in advance, for the services you have requested. By signing, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment. If you are a federal health program beneficiary, you agree that neither you, Midi, IWC, or any of the health care organization(s) or provider(s) with whom we partner to provide health care services to you will submit a claim for reimbursement to any federal or state healthcare program for the costs of the services and products provided to you through the services.
I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.