CLIENT RESPONSIBILITY FOR PAYMENT OF HOME HEALTH CARE SERVICES
1. I UNDERSTAND THAT HE NURSE REGISTRY/HOME HEALTH CARE AGENCY WILL PROMPTLY PRESENT CLAIMS FOR THE PAYMENT OF MY HOME HEALTH CARE SERCICES TO MY INSURANCE COMPANY.
2. I ALSO UNDERSTAND THAT I’M RESPONSIBLE FOR THE ENTIRE HOME HEALTH CARE BILL OR BALANCE OF THE SAME BILL AS DETERMINED BY, IF SUBMITTED CLAIM OR ANY PART OF THEM IS DENIED FOR PAYMENT.
3. I UNDERSTAND THAT IF FIRST-CLASS NURSING REGISTRY IS DELAYED IN REQUESTING IMMEDIATE PAYMENT, IS SHALL NOT RELEASE ME OR MY ESTATE FROM THE OBLIGATION TO PAY THE HOME HEALTH CARE AGENCY/NURSE REGISTRY.
ASSIGNMENT OF INSURANCE BENEFITS
I, ___________________________________________, AUTHORIZE DIRECT PAYMENT TO FIRST-CLASS NURSING REGISTRY OF ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR PROVIDED PRODUCTS OR SERVICES. I ALSO AUTHORIZE MY INSURANCE COMPANY (IES) TO FURNISH TO FIRST-CLASS NURSING REGISTRY, ANY AND ALL INFORMATION PERTAINING TO MY INSURANCE BENEFITS AND STATUS OF CLAIMS DOES NOT ACCEPT “ASSIGNMENT OF BENEFIT”, I WILL HOLD IN TRUST ANY CORRESPONDENCE AND PAYMENTS RECEIVED AND WILL PROMPTLY SUBMIT THEM TO FIRST-CLASS NURSING MUST PURSUE ME LEGALLY, I WILL BE RESPONSIBLE FOR ALL COSTS, INCLUDING ATTORNEY’S FEES. …show more content…
NSURANCE HAVE ELIMINATION PERIOD OF_______ DAYS, HOW MANY MET _______ OF _______ DAYS.
INSURANCE COVERS FOR RN ASSESSMENT OF: ________________________________.
INSURANCE COVERS FOR H.H.A.C.NA. ____________PER HOUR/ PER LIVE IN_________________.
I AGREE TO ABIDE BY ALL OF THE ABOVE CONDITIONS AND I ACKNOWLEDGE THAT THIS AGRE3EMENTS SHALL BIND ME AND MY HEIRS, EXECUTORS, ADMINISTRATORS, AND ASSIGNS.
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT AND I HAVE EXECUTED SAID AGREEMENT OF MY OWN FREE WILL, EFFECTIVE OF THE DATE
1. I UNDERSTAND THAT HE NURSE REGISTRY/HOME HEALTH CARE AGENCY WILL PROMPTLY PRESENT CLAIMS FOR THE PAYMENT OF MY HOME HEALTH CARE SERCICES TO MY INSURANCE COMPANY.
2. I ALSO UNDERSTAND THAT I’M RESPONSIBLE FOR THE ENTIRE HOME HEALTH CARE BILL OR BALANCE OF THE SAME BILL AS DETERMINED BY, IF SUBMITTED CLAIM OR ANY PART OF THEM IS DENIED FOR PAYMENT.
3. I UNDERSTAND THAT IF FIRST-CLASS NURSING REGISTRY IS DELAYED IN REQUESTING IMMEDIATE PAYMENT, IS SHALL NOT RELEASE ME OR MY ESTATE FROM THE OBLIGATION TO PAY THE HOME HEALTH CARE AGENCY/NURSE REGISTRY.
ASSIGNMENT OF INSURANCE BENEFITS
I, ___________________________________________, AUTHORIZE DIRECT PAYMENT TO FIRST-CLASS NURSING REGISTRY OF ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR PROVIDED PRODUCTS OR SERVICES. I ALSO AUTHORIZE MY INSURANCE COMPANY (IES) TO FURNISH TO FIRST-CLASS NURSING REGISTRY, ANY AND ALL INFORMATION PERTAINING TO MY INSURANCE BENEFITS AND STATUS OF CLAIMS DOES NOT ACCEPT “ASSIGNMENT OF BENEFIT”, I WILL HOLD IN TRUST ANY CORRESPONDENCE AND PAYMENTS RECEIVED AND WILL PROMPTLY SUBMIT THEM TO FIRST-CLASS NURSING MUST PURSUE ME LEGALLY, I WILL BE RESPONSIBLE FOR ALL COSTS, INCLUDING ATTORNEY’S FEES. …show more content…
NSURANCE HAVE ELIMINATION PERIOD OF_______ DAYS, HOW MANY MET _______ OF _______ DAYS.
INSURANCE COVERS FOR RN ASSESSMENT OF: ________________________________.
INSURANCE COVERS FOR H.H.A.C.NA. ____________PER HOUR/ PER LIVE IN_________________.
I AGREE TO ABIDE BY ALL OF THE ABOVE CONDITIONS AND I ACKNOWLEDGE THAT THIS AGRE3EMENTS SHALL BIND ME AND MY HEIRS, EXECUTORS, ADMINISTRATORS, AND ASSIGNS.
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT AND I HAVE EXECUTED SAID AGREEMENT OF MY OWN FREE WILL, EFFECTIVE OF THE DATE