Assignment of Benefits
Agreement to Pay
By signing below, I agree that:
- The information I am giving you is correct.
- Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A. Cloud Health Medical Group of Kansas, P.C., Cognitive Nutrition & Wellness LLC and Pesto Health, Inc. (collectively “Providers”) and my doctor may release or share any information needed to process my claims, including with a division of state or local government authorized to reimburse my claims.
- Providers and those providing my care shall be paid or assigned benefits on my behalf.
- I will cooperate with and provide documentation to my insurance company or other third-party payer as needed to process my claims.
- I am responsible for any costs not covered by my benefits, including non-covered services, deductibles, and co-insurance.
Assignment of Benefits
I request and agree that any benefits due me for my treatment by all insurance companies or other third-party payers responsible for my care shall be paid or assigned to Providers. This includes any insurance company settlements related to my treatment. If my insurance company or other payer will not pay Providers directly for my care and treatment at Providers, I will immediately forward payments I receive to Providers.
Non-covered Services
I understand that my insurance or payer may not cover all my costs. I agree that I am personally responsible for:
- any costs not covered by my insurance or payer or that exceed my benefit limits, including, but not limited to:
- self-administered medications (medicines you would normally take on your own)
- certain durable medical equipment
- certain medical supplies
- services and supplies that my insurance or payer determines are experimental or investigational or are not covered for some other reason, or that are not medically necessary but that I want to receive.
CMS Governed Plans
If you are a beneficiary of a government health program, you agree that neither you, your healthcare provider, the affiliated physician practices, nor any of the healthcare organization(s) or provider(s) with whom we partner to provide healthcare and pharmacy services to you will submit a claim for reimbursement to any federal or state healthcare program except Medicare Advantage plans for the costs of the services and products provided to you through the Services. Submission of claims to Medicare Advantage plans is expressly permitted. All other government program claims (e.g., Medicare Part B (FFS), Medicaid, Tricare, Veterans Affairs) are strictly prohibited.
Guarantor Agreement
I understand and agree that:
- I - or the person signing or guaranteeing payment for me (Guarantor) - am responsible for any charges not covered by my insurance, for any reason. Such charges are due when my treatment stops or I am discharged.
- I can ask for an estimate of the charges based on the Providers pricelist (“chargemaster”) in effect at the time of service. This estimate may need to be prepared and mailed to me. It will only be an estimate. Actual costs may vary.
- Providers may bill my insurance for me. But Providers may also ask me to pay in full in advance, unless Providers agrees with my insurance company or other payer not to do this.
- I may be billed by Providers.
- I am responsible for all charges and that this agreement covers all Providers accounts, including those for doctors, nurse practitioners, and physician assistants. Should my bill be sent for collection, I will pay any costs that may result, including attorney’s fees, court costs, and collection agency fees associated with the collection process.
- Providers and its providers, affiliates, agents and contractors, including debt collectors, may call or text my cell or home phone using any type of artificial or pre-recorded voice or auto-dialer technology for any purpose, including billing and collections.
- Providers may access my consumer credit report to help collect what I owe or to see if I am eligible for financial aid or charity care.