FORM #: 1030
Patient ID: _________________
PRIMARY INSURANCE INFORMATION
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 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.
Please write Patient/Guardian full name below which serves as electronic signature.