ASSIGNMENT OF MEDICAL BENEFITS - Orthotics

Regulations authorize Medicare to pay for claims submitted by a supplier only if the Beneficiary or the person authorized to request payment on the Beneficiary's behalf assigns the claims to the supplier and the supplier accepts assignment. Nationwide Medical, Inc. can only receive Medicare payment if the Beneficiary (patient) assigns his or her Medicare benefits to Nationwide Medical, Inc. In accepting the assignment, we accept Medicare's determination of the approved amount as the full fee for the service(s) rendered. Please sign and date the statement below and return it at your earliest convenience. Thank you for your cooperation.




I (the patient and/or Caregiver) authorize Nationwide Medical, Inc. to obtain or release to the Healthcare Financing Administration, any third party payor, and their respective agents, any medical information about me, needed to determine benefits payable and/or patient care on my behalf.

I request that payment of authorized Medicare benefits be made on my behalf to Nationwide Medical, Inc. (supplier) for any services furnished to me by Nationwide Medical, Inc. As the supplier of services for this patient, Nationwide Medical, Inc. assumes unconditional responsibility for refunding any overpayment resultant of the carrier not having received prompt notice of the return of, or the end of need for the supplies, or the demise of the enrollee. I authorize Nationwide Medical, Inc. to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.





HIPAA Auhorization for Release of Information

Your Information









Person/Organization Providing the Information
[45 C.F.R.§ 164.508(c)(ii) & Civ. Code § 56.11(c)]

Person/Organization to Receive the Information
[45 C.F.R.§ 164.508(c)(iii) & Civ. Code § 56.11(f)]

Nationwide Medical Inc.:
28632 Roadside Dr#210, Agoura Hills, CA 91301
Ph: 877-301-2727 Fax: 866-649-2727
Please Fax Report ASAP!

Description of the Information to be Released (Detailed Description)
[45 C.F.R. § 164.508(c)(i)& Civ. Code § 56.11(d) & (g)]]
This is for the release of medical records related to the treatment and diagnosis of Deg. Disc Disease, Spinal Stenosis, Spondylosis w/o Myelopathy, Spondylosis with Myelopathy, Lumbago, Myospasm, Sciatica, Herniated Nucleus Pulposus, Rheumatoid Arthritis, Other Specified Inflammatory Polyarthropathies, Lumbar Sprain/Strain, Spinal Instability.
Description of Each Purpose for the Use or Release of the Information (Detailed Description)
[45 C.F.R. § 164.508(c)(iv)]
The purpose of the release of this information is to support the necessity of the use of the DDS 500 Lumbar Spinal-Air Decompression LSO Brace.


[45 C.F.R. § 164.508(a)(3)]

Yes

No

This authorization for release of the above information to the above named persons/organizations will expire on: 2 years from date of signature:
[45 C.F.R. 164.508(c)(v) & Civ. Code § 56.11(h)]


I understand:

  • I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. I understand that this authorization is voluntary. [45 CFR § 164.508(c)(2)(i)]
  • I have the right to revoke this authorization by sending a notice stopping this authorization to Arlene Gonzalez at 818-338-3521. The authorization will stop on the date my request is received. [45 C.F.R. § 164.508(c)(2)(ii)& Civ. Code § 56.11(h)]
  • I understand the Notice of Privacy Practices provides instructions should I choose to revoke my authorization. [45 C.F.R. § 164.508(c)(ii)]
  • I understand that I cannot revoke this authorization because the covered entity has taken action in reliance on the authorization. [45 C.F.R. § 164.508(c)(2)(i)]• I understand that I am signing this authorization voluntarily and that treatment, payment or eligibility for my benefits will not be affected if I do not sign this authorization. [45 C.F.R. § 164.508(c)(2)(ii)]
  • I understand that I am signing this authorization voluntarily and that treatment, payment or eligibility for my benefits will be affected if I do not sign this authorization. The consequences for my refusal to sign this authorization will be none.[45 C.F.R. § 164.508(c)(2)(ii)]
  • I understand if the organization I have authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. [45 C.F.R. § 164.508(c)(2)(iii)]
  • I understand I have the right to receive a copy of this authorization. (Civ. Code § 56.12)
I understand that by typing my name and by typing "I ACCEPT" below, and clicking on the save and continue button below, constitutes my eSignature, and by my eSignature, I certify that I have read, fully understand, and accept all terms of the foregoing statement. I understand that my electronic signatures will be binding as though I had physically signed these documents by hand. I agree that a printout of this authorization may be accepted with the same authority as the original. Please signify your acceptance by entering the information requested in the fields below.



CONFIDENTIALITY NOTICE: The information contained in this facsimile message is confidential information belonging to the sender and is legally privileged. The information is intended only for use by the recipient. You are hereby notified that any disclosure, copying, distribution or the taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this privileged communication in error, please notify the above-designated sender immediately by calling the above-designated office to arrange for the return of the telecopied, privileged information. Thank you