Forms – Insurance Direct Billing Authorization

FORM #:  1030

Patient ID: _________________

PRIMARY INSURANCE INFORMATION

POLICY HOLDER INFORMATION (Only if different from patient)

Message to the Plan member, Spouse and/or Dependent regarding Personal Information:

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse.

• I authorize my healthcare provider/ Physiomobility to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or administrator and their service provider(s) for the above purposes. I authorize the insurer and/or plan administrator and their service provider(s) to:
  
• Use my personal information for the above purposes
  

• Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs relevant for the above purposes.
  

• Exchange personal information concerning any claims submitted with the plan member or person acting on behalf of the plan member.
  
• Exchange personal information for the above purposes electronically or in any othermanner. I understand that personal information may be subject to disclosure to those authorized under applicable law.
  

I agree that a photocopy or electronic version of this authorization shall be as valid as the original and may remain in effect for the continued administration of the group benefits plan.

I authorize Physiomobility Health Group to bill my insurance company directly. I understand that Physiomobility will bill the insurance company after the service is provided. I authorize the payment to be directly paid to Physiomobility and I will be personally liable for any outstanding balance not covered by my insurance company. I will notify Physiomobility if the payment from the insurance company is paid directly to my account. I understand that if for any reason Physiomobility Health Group does not receive payment within 30 days of the service date, I will be responsible for the payment.