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. and their affiliated providers (collectively “Providers”) may release or share any information needed to process 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 authorize and request that the payment of the proceeds of any insurance benefits for which I (or my dependent) am a beneficiary be made on my behalf directly to Providers as payment for services rendered to me. 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 by Providers, I will immediately forward payments I receive for such care, including through a claim or lawsuit, to Providers.

I also hereby irrevocably assign to Providers all benefits provided by third-party insurance payers under any policy of insurance, indemnity agreement, or any collateral source as defined by statute for services provided by Providers. This assignment includes all of my rights and interests in all such insurance benefits or proceeds for such services, including the rights to: (1) request and receive any documents or information from any entity or person, to the full extent of my rights; (2) appeal any denial or underpayment of benefits or coverage under any benefits plan; and (3) pursue any legal remedies I may have now or in the future that relate to the services and that are available under applicable law or any health plan, in any forum, and be awarded all available relief (monetary or equitable).

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 or are otherwise not covered; and
• 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 I am a beneficiary of a government health program, I agree that neither I nor the Providers 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 me through by the Providers. Submission of claims to Medicare Advantage plans is expressly permitted.

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 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.

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