By utilizing DoctorNow’s services you hereby agree to the following:
A. I understand that I’m responsible for providing correct and accurate insurance
information so DoctorNow can bill my insurance. I consent to the use and disclosure of
my/the patient's protected health information for purposes of obtaining payment for
services rendered to me/the patient, treatment and treatment and health care operations
consistent with DoctorNow's Notice of Privacy Practices.
B. Assignment of benefits, authorization to settle claims & direction to pay medical provider
I, the undersigned, irrevocably assign DoctorNow all of my rights and benefits
and any other interests that I have in any medical insurance plan, health benefit
plan, indemnity plan, trust, fund or other source of payment for healthcare
services (each a "Plan") in connection with medical and/or laboratory services
provided by DoctorNow, its employees and agents. I understand that this
document is a direct assignment of my rights and benefits under my Plan.
I instruct my insurance company to pay DoctorNow directly for the professional or
medical expense benefits payable to me. In addition, I agree and understand that
any funds I receive from my insurance company due for services rendered by
DoctorNow will be immediately signed over and sent directly to DoctorNow.
This is a direct and irrevocable assignment of my rights and benefits under my
policy of insurance.
C. Authorization to Bill, Settle, and Appeal Insurance Claims by DoctorNow
I hereby authorize DoctorNow to bill my health insurance for services provided by
DoctorNow according to the following terms:
a. Authorization will start on the date services are provided and stay in effect
until claims for services are resolved and paid for by either you or your health
b. DoctorNow will act as the authorized representative for claims processing.
c. Protected Health Information will be disclosed in a confidential manner during
the billing process and may be disclosed to an authorized representative.
d. I may revoke authorization at any time.
e. Revoking authorization prior to a claim being resolved with my health plan
may result in financial responsibility being transferred to me, the patient.
I have read the foregoing and understand and agree to each of the above provisions.