I hereby authorize Active Life to request any medical records/documents pertaining to the services Active Life is providing from any of my medical providers should my insurance or other medical provider require it.
I hereby assign all medical insurance benefits to which I am entitled to Active Life I also authorize Active Life to be my personal representative thereby allowing them to submit any and all appeals when my insurance company denies me benefits to which I am entitled. I also authorize my insurance carriers to issue payment directly to Active Life for any services furnished to me by Active Life. I understand I will be responsible for any unmet deductibles, co-payments or co-insurance. I also understand and agree that I am responsible for FULL payment of my medical debt if my insurance company has refused to pay within 90 days of any and all appeals or requests for information. If I do not pay my balance due within 90 days my account may be turned over to a collection agency.
It is the patient’s responsibility to understand the benefits of their insurance plan. Many plans have changed and it is important for to know what will be covered. Please be advised that a precertification or prior authorization from your health plan is NOT a guarantee of payment. Co-payments are due at the time of delivery along with any outstanding balance from a previous visit and you are responsible for giving us current insurance information and any change of physician.