In consideration of Change in Motion (“CIM”) undertaking to provide services to me, I hereby agree that I am responsible to CIM for payment of all such services.
I understand that some, or perhaps even all, of the services provided by CIM may be considered uncovered services, and therefore not payable by my insurance company.
I hereby absolutely authorize CIM to apply for benefits on my behalf for services rendered to me and request that payment be made by my insurance company and that payments be sent directly to CIM. If I have active and valid insurance coverage, I have supplied CIM with the up-to-date and correct insurance identification card(s). In the event payment of insurance benefits for services provided by CIM is made to me directly by my insurance company, I hereby agree that within thirty (30) days of receipt, I shall endorse the insurance company’s check or other instrument to the payment of CIM and deliver it to CIM, along with any accompanying explanation of benefits (“EOB”). I further authorize CIM to charge any credit card, or withdraw funds from any account that I have provided the full amount of any insurance benefits received by me directly, in the event I fail to endorse and deliver the endorsed insurance company’s check or other instrument, along with the EOB, to CIM within thirty (30) days of receipt; and in such event acknowledge that CIM may impose a surcharge of Five Percent (5%) of the amount of such insurance benefits to cover CIM’s administrative costs. I hereby further irrevocably assign my rights to benefits under my contract of insurance or other third party payment to CIM, as well as all benefits payable to me under my insurance policy and health benefits plan.
I hereby authorize CIM to release any information relating to any claim for benefits, in order to process any claim for benefits and to secure the payment of benefits. I may revoke this authorization at any time in writing.
I understand and agree that CIM may charge the credit card or withdraw funds from the account that I provided Fifteen Percent (15%) of the charge for the service for any missed visit (not available to receive CIM services within 15 minutes of the scheduled start time). In the event I do not have a credit card or account on file with CIM, I shall pay any such charges promptly.
I certify that I have read the above information, or that the information has been read or translated to me, and that I understand my rights and obligations as a client of CIM under this agreement.
