Financial Agreement and Assignment of Benefits
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS
I agree to be responsible for the payment of all fees (“Fees”) related to the services provided to me by OnCall Health of NJ, PC d/b/a Cayaba Care (“Cayaba”) and its physicians and personnel (the “Services”). I understand that Cayaba will bill my insurance carrier, as a courtesy to me, based on the information I provide to Cayaba. Any portion of the Fees that is not paid by my insurance carrier to Cayaba shall remain my sole responsibility.
I hereby authorize Cayaba to submit claims to my insurance carrier for payment of all Fees for the Services, and agree to cooperate with Cayaba in providing all necessary information and authorization for submission of such claims.
I agree to pay all co-pays, co-insurance and deductibles due under my insurance plan to Cayaba on the date of service.
If I do not have insurance coverage, I understand and agree that I will be responsible for payment of all Fees to Cayaba.
I irrevocably assign to Cayaba, all of my rights and benefits and any other interests that I have in my insurance plan in connection with the Services. I understand that this document is a direct assignment of my rights and benefits under such plan. I instruct my insurance plan to pay Cayaba directly for the professional or medical expense benefits payable to me, and, if direct payment is not permitted, to mail a check in my name to Cayaba, which I hereby irrevocably authorize Cayaba, as my special power of attorney, to endorse over to it in payment of the Fees.
I hereby authorize Cayaba to charge any credit card I have given to Cayaba in the patient intake process to pay for all co-pays, co-insurance or deductibles due for the Services and all unpaid Fees that are my responsibility hereunder.
By signing, I agree to all of the terms of this Financial Agreement and Assignment of Benefits: