This agreement is entered into this date by and between hereinafter “Patient” and Prime
Diagnostic Imaging, JTP Diagnostics, Foundation Physicians Group, Cellular Medicine Solutions, hereinafter “Provider”. Whereas Patient
desires to receive healthcare services from Provider and desires to assign certain rights and benefits to Provider as an inducement to
cause Provider to wait for payment of such benefits, it is hereby agreed:
SECTION 1. Patient assigns to Provider any and all benefits payable by Patient’s insurance or healthcare plan(s) as a result of charges
incurred by Patient for services rendered by Provider. Patient also assigns to Provider any and all contractual rights Patient has against
any insurance company, healthcare benefit plan or any other party contractually liable to Patient for payment of healthcare costs
incurred by Patient as a result of services rendered by Provider. This assignment of benefits and contractual rights to those benefits shall
not exceed the total amount of charges incurred by patient for services rendered by Provider. Patient agrees that payment for services
rendered by Provider is due upon receipt of said services and Provider’s acceptance of patient assignment of benefits is a convenience
to Patient and that Provider may revoke this assignment at any time.
SECTION 2. Patient thereby directs all insurers and other persons responsible for Patient’s healthcare costs to make all payment for the
healthcare services rendered by Provider directly to Provider.
SECTION 3. Patient agrees to waive any applicable statute of limitations which may at any time interfere with Provider’s right to collect
for services rendered to Patient.
SECTION 4. Patient agrees that in the event Patient receives any check, draft or other payment subject to this Agreement, patient will
act as a fiduciary agent for Provider and will immediately deliver said check, draft or payment to Provider. Provider agrees to apply the
proceeds from the check, draft or payment to Patient’s debt for services rendered.
SECTION 5. A copy of this document shall be as binding as the document bearing original signatures. At the time each claim is
submitted, a copy of the claim will be stored for safekeeping in Patient’s file and may be picked up by the Patient/insured at any time or
will, upon request by the Patient/insured or be mailed to a designated address.
SECTION 6. Patient agrees to be responsible for any deductibles or co-payments required by the terms of any applicable insurance or
healthcare plan. Patient further agrees to pay for any services not covered by Patient’s insurance or healthcare plan. A refund, if any, will
be calculated upon receipt of payment from your insurance company.
SECTION 7. In the event that any Section or provision of this Agreement is legally void, invalid or unenforceable, all other sections and
provisions of this Agreement shall remain in full force and effect.
SECTION 8. Provider participates/contracts with many, but not all insurance companies. Provider can be determined dependent on the
type of service provided. Contracts are not all the same and certain services may not be covered depending on your benefits. Whether
provider participates with an insurance company or not, you must pay your co-payment, coinsurance and/or remaining deductible at
the time of service. Imaging services may be billed globally or split, technical and professional. You may receive one or two bills. Pain
procedures may be billed by up to three providers, physician, facility, and anesthesiology.
IN WITNESS THEREOF, this agreement has been explained to the (patient’s) satisfaction and having due knowledge and understanding
entered into the day and year set forth below.
Patient Signature Date
Guardian (If patient is a minor) Date
Prime Diagnostic Witness Date
BENEFIT ASSIGNMENT RECORD
RELEASE PAYMENT AGREEMENT
6.
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