ASSIGNMENT OF INSURANCE BENEFITS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I hereby authorize Alpha Vascular Screenings LLC to bill my insurance carrier or any other payment source. I assign all benefits and authorize payments directly to Alpha Vascular Screenings LLC for any benefits otherwise payable to me for all claims for such services provided. I understand I am finicially responsible to Alpha Vascular Screenings LLC for charges not covered by this assignment. This assignment of benefits will be effective until revoked by me in writing. Such revokation shall have a prospective effect only. I authorize the release of any medical or other information necessary to process this claim.
When necessary, we may share your name, date of birth, screening proceedure code and/or insurance plan information with your employer, if they are scheduling your appointment, paying for services or giving you credit for participating in a wellness program; however, your test results will not be shared without your written permission.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I received and/or was offered a copy of Alpha Vascular Screenings LLC Notice of Privacy Practices. I understand this organization has the right to change its Notice of Privacy Practices from time to time and I may contact Alpha Vascular Screenings LLC to obtain a current copy.
I have read and agree to all the information above. I certify the information I have provided is accurate to the best of my knowledge. A photocopy, electronic copy or scan of this agreement may be used as though it were an original