Assignment of Benefits and Payment

Assignment of Benefits

I hereby irrevocably assign and transfer to Mira Mace any monies or benefits to which I may be entitled, including benefits/monies from governmental payers such as Medicare, my insurance company, HMO, or other third parties who are financially responsible for my medical care (each a “Plan” and collectively the “Plans”).

I authorize and direct Mira Mace and its physicians, employees, and agents, having treated me, to release to such payers or other third parties who are financially responsible for my medical care, all information needed (including but not limited to medical records, copies of claims and itemized bills) to substantiate payment for my medical care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment.

I also appoint Mira Mace as my authorized representative to pursue all rights of payment, to ascertain the benefits available, to collect benefits directly from my insurance company and to appeal denials and proceed against my insurance company in any action, including legal suit, on my behalf if for any reason my insurance company refuses to pay my claim. The appointment shall include all rights to recover attorney’s fees and costs for such action brought by Mira Mace as my assignee.

I further agree to provide information as necessary and to cooperate with Mira Mace to process and obtain payments. I understand that this document is a direct assignment of my rights and benefits under my Plans.

Patients Entitled to Medicare Benefits

I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical information about me to release it to the Social Security Administration and the Centers for Medicare and Medicaid Services or its intermediaries or carriers for the purpose of payment. I request that payment of authorized benefits related to my care be assigned to Mira Mace.

Recognition of Separation

Mira Mace is separate from MiraMace, Inc., which conducts payment and administrative services for Mira Mace.

Guarantee

I understand that I am financially responsible for charges not covered by insurance. I agree to pay all amounts for which I am responsible for medical services rendered in accordance with the rates and terms of Mira Mace or as determined by my Plan.

Digital Copy

I agree that a digital copy of this agreement shall be valid as the original.