1. Direct Billing Electronic Transmission Authorization and Consent Form
Provider: Top Rehab
Address: 11B-512 Bristol Rd West, Mississauga ON L5R 3Z1
Phone Number: 905-507-1808
Client Name:
Date of Birth: Phone Number:
Address:
Insurer(Insurance company): Policy#, Plan# or Contract No:
Certificate# or.member ID or Plan member Number(gsc holder only fill this):
Patient code: (for member with Nexxgen,the Cooperators only, such as 001)
GMS Carrier50 or Carrier49? (for member with GMS coverage under Telus)
Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient’s behalf and when claim payment is assigned to the Provider. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.
Consent to Collect and Exchange Personal 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.
Authorization and Consent
I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.
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 when relevant for the above purposes.
exchange personal information concerning any claims submitted with the plan member or a personacting on behalf of the plan member.
exchange personal information for the above purposes electronically or in any other manner.
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.
Additional Consent Applicable to Plan Members Only
p class="additional-content">I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal informationabout them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies,regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount
2. Direct Billing Consent to Benefit Assignment Form
I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider.n the event my claim(s) are declined or not processed with paid amount to the clinic stated by the insurer, I understand that I remain responsible for payment to the Provider/Clinic for any services rendered and/ or supplies provided.Please note that we cannot bill your service till it started, which is regulated by the insurance company to prevent the fraud activity happened.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/planadministrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.
2.Does your plan need a Doctor Prescription for the paramedical services (please circle)? Yes No
3.Only for Nexxgen, cooperators, Do you want any unpaid balances to be paid from your HCSA account? Yes No
if the current prescription already expired, you must provide your insurance company a valid one