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* 1. Client Name (surname, first name):

DIRECT BILLING TO EXTENDED BENEFITS PLANS
At Resolution Physiotherapy & IMS Clinic we are able to bill directly to most extended medical plans.  Please provide us with extended medical information for you and your spouse and we will determine if your insurance company allows for direct billing.

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* 2. Insurance/Benefits (if applicable)

The following is a requirement of extended benefits plans where you authorize Resolution Physiotherapy & IMS clinic to bill electronically on your behalf and authorize for payment to come directly to Resolution Physiotherapy & IMS Clinic.  

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* 3. BENEFIT ASSIGNMENT
I hereby assign benefits payable for the eligible claims to Resolution Physiotherapy & IMS clinic who will be submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to Resolution Physiotherapy & IMS Clinic. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to Resolution Physiotherapy & IMS Clinic for any services rendered and/ or supplies provided. 

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/plan administrator 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 Resolution Physiotherapy & IMS Clinic 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.

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* 4. ELECTRONIC TRANSMISSION AUTHORIZATION & CONSENT FORM

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. 

I 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 person acting 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 an 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 

I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about 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 payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.

Thank you for completing Resolution Physiotherapy & IMS Clinic's direct billing documentation.

When you are finished, please click on 'done'.

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