I request that payment of authorized insurance benefits, including Medicare if I am a Medicare
Beneficiary, be made either to me or on my behalf to the organization listed below for any
equipment or services provided to me by that organization. I hereby assign and convey directly to
the below-named health care provider ("Provider"), as my designated authorized representative, all
medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services,
treatments, therapies, and/or medications rendered or provided by the Provider, regardless of its
managed care network participation status.
I understand that I am financially responsible to the Provider for any charges regardless of health
care benefits. It is my responsibility to notify the Provider of any changes in my health care
coverage. In some cases exact insurance benefits cannot be determined until the insurance
company receives the claim. I am responsible for the entire bill or balance of the bill as determined
by the Provider and/or my health care insurer if the submitted claims or any part of them are denied
I hereby authorize the Provider to release all medical information necessary to process my claims.
Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the
Provider any and all plan documents, summary benefit description, insurance policy, and/or
settlement information upon written request from the Provider or its attorneys in order to claim such
In addition, I also assign and/or convey to the Provider any legal or administrative claim or choose an
action arising under any group health plan, employee benefits plan, health insurance or tort feasor
insurance concerning medical expenses incurred as a result of the medical services, treatments,
therapies, and/or medications I receive from the Provider (including any right to pursue those legal
or administrative claims or choose an action). This constitutes an express and knowing assignment of
ERISA breach or fiduciary duty claims and other legal and/or administrative claims.
I intend by this assignment and designation of authorized representative to convey to the Provider
all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments,
therapies, and/or mediations provided by the Provider, including rights to any settlement, insurance
or applicable legal or administrative remedies (including damages arising from ERISA breach of
fiduciary duty claims). The assignee and/or designated representative (Provider) is given the right by
me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3)
make statements about facts or law; (4) make any request including providing or receiving notice of
appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or
choose in action or right against any liable party, insurance company, employee benefit plan, health
care benefit plan, or plan administrator. The Provider as my assignee and my designated authorized
representative may bring suit against any such health care benefit plan, employee benefit plan, plan
administrator or insurance company in my name with derivative standing at Provider's expense.
Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA
(health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy
of this assignment is to be considered valid, the same as if it was the original.
PROVIDER: K Scott Danoff, DMD, 49-33 Little Neck Parkway, Little Neck, NY 11362
I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
I have attempted to use the nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reasons:
Because of my intolerance/inability to use the CPAP, I wish to have an alternative method of treatment. That form of therapy is oral appliance therapy (OAT).
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