It is our policy, for your convenience, as well as to facilitate payment, to file health benefit claims on your behalf. To enable your insurance policy or benefit plan to deal with us directly.
Assignment of Benefits
I hereby assign and convey to the fullest extent permitted by law any and all benefits and non-benefit rights (including the right to any payments) under my health insurance policy or benefit plan to Dr. Frank Femino, Dr. Stephen Ducey, and Nutley Orthopaedic Group (collectively, the “Providers'') with respect to any and all medical/facility services provided by the Providers to me for all dates of service. It is specifically intended by this assignment of benefits to assign to the fullest extent permitted under the law any and all of my rights, including without limitation, the right of one or more of the Providers, or their attorney (or other representative to (i) execute, in my name and on my behalf, any form, document or instrument required under any applicable insurance policy or benefit plan to further evidence my intent as set forth herein and to avoid any delay in pursuing rights under applicable Federal and State laws, regulations and requirements, (ii) pursue penalties for and exclusively on behalf of Providers against any insurance policy or benefit plan for failure of the plan administrator to timely produce and respond to requests (including appeals) for all information relating to any plan documents describing the rights under any insurance policy or benefit plan as required by any applicable Federal or State law, (iii) to endorse for me any checks made payable to me for benefits and claims collected toward my account, and/or in the event the insurance carrier responsible for making medical payments to Dr. Frank Femino, Dr. Stephen Ducey, and Nutley Orthopaedic Group for medical services rendered to me does not accept my assignment of benefit rights, or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and authorize Provider’s attorney (or other representative) as my agent and attorney, in fact.
Designated Authorized Representative
I hereby appoint as a Designated Authorized Representative each of my Providers and each of their respective assistant surgeons, physician assistants, teaching assistants, billing staff, lawyers (including the Law Offices of Cohen and Howard) or any other person or business that provides healthcare activity services as a “business associate” under the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”), and their respective designees (collectively referred to herein as an “Authorized Representative”). This authorization is intended to comply with all requirements of the Employment Retirement Income Security Act of 1974, as amended (“ERISA”) and any applicable State law. Each authorized Representative is granted the same rights which I have as a member or beneficiary under my insurance policy or benefit plan, including without limitation:
- The right of my Authorized Representative to file claims for benefits on my behalf and directly receive payment for benefits and non-benefits from any third-party payer under my insurance policy or benefit plan, including the right to penalties, interest and attorney fees.
- The right of my Authorized Representative to communicate with insurers, plan fiduciaries, employers and plan and claim administrators relative to all my benefit information and private health information (“PHI” as further defined under HIPAA) and to share and exchange such information with a “covered person” or “business associate” as those terms are defined under HIPAA.
- The right of my Authorized Representative to send a receive follow-up information and obtain all documentation that ERISA or any State law requires to be provided to me, including, without limitation, plan documents involving my claim, identity of all persons involved in determining my claim and all
documents relied upon in making any determination as to payment of any amount under the applicable plan documents.
- The right of my Authorized Representative to file any internal or external member appeal for payment of benefits under any applicable insurance policy or benefit plan.
- The right of my Authorized Representative to pursue any rights, claim or cause of action through pre-litigation demands, demands for payment, arbitration, independent dispute resolution or administrative proceeding, litigation or otherwise under any Federal or State law with respect to payment for services provided by a Provider to me, including penalties, interest and attorney fees.
Release of Private Health Information
It is specifically intended that any Provider or Authorized Representative is authorized and directed to provide and release my PHI for purposes of exercising all rights and authorization to any “covered person” or “business associate”, including third-party payers, internal and external utilization review organizations, regulatory review entities and other organizations and/or companies that may/will assist with claims processing/reimbursement. I also direct any plan or claim administrator or plan sponsor to share all PHI with any Provider or Authorized Representative and not to inhibit the exercise of right under my insurance policy or benefit plan by requiring any further authorization signed by me.
I, the patient, consent to medical treatment by Dr. Frank Femino MD and/or Dr. Stephen Ducey MD, and I hereby authorize Nutley Orthopaedic Group to furnish information to insurance carriers concerning my illness and treatment. I hereby assign to Nutley Orthopaedic Group all payment for medical and or surgical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. I agree to pay all costs of collection, including a reasonable attorney's fee, should this account be placed with an attorney for collections.
I understand that I remain fully responsible for any billed charges remaining due for services provided to me by a Provider, including co-pays, co-insurance and deductibles. If I receive any check or other payment from an insurance company or third-party payer for services rendered to me by a Provider, I will immediately endorse the check over to the Provider or otherwise make payment to the Provider for the amount of payment received from such insurance company or third-party payer. I agree that if the Provider is required to pursue collection efforts against me for these amounts, I will be responsible for all legal fees, interest and costs associated therewith.
This Assignment of Benefits/Designated Authorized Representative authorization/Limited Special Power of Attorney shall remain in full force and effect for all current and future dates of service, until such time that all rights have been exercised under applicable Federal and State law as determined by Providers. I may revoke or withdraw this authority upon written notice to the Providers. In the event of any revocation, I will be responsible for payment of all outstanding amounts then due to the Providers.