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  • MEDICARE ASSIGNMENT OF BENEFITS,
    AUTHORIZATION FOR RELEASE OF INFORMATION,
    AND ACKNOWLEDGEMENT OF RIGHTS AND RESPONSIBILITIES


  • By my signature on the following page, I certify the following:

  • Assignment of Medicare Benefits
    I request that payment of authorized Medicare benefits be made on my behalf to Cindy Lerner Counseling and I authorize Cindy Lerner Counseling to release any medical information about me to the Centers for Medicare & Medicaid Services and its agents that is needed to determine these benefits or the benefits payable for related services.

  • Assignment of Other Benefits
    I request that payment of any other authorized insurance benefits be made on my behalf to Cindy Lerner Counseling for any services provided to me by Cindy Lerner Counseling. I authorize Cindy Lerner Counseling and its agents to release any medical information about me to the health plan or other entity providing such benefits for purposes of facilitating payment of such benefits.

  • My Payment and Notification Responsibilities
    I agree that I am responsible for any deductible, coinsurance payment, and potentially other amounts not covered by Medicare or by any other insurance, except as otherwise prohibited by law. I agree that I will notify Cindy Lerner Counseling immediately of any changes in my insurance coverage or insurance provider(s).

  • Notice of Privacy Practices and Patient Bill of Rights
    By providing my e-mail address below, I consent to receive copies of Cindy Lerner Counseling’s Notice of Privacy Practices (https://www.cindylernercounseling.com/privacy-policy/) electronically. I understand that a printed version will be provided to me upon request.

  • Certification Statement
    I CERTIFY THAT THE INFORMATION I FURNISH IS TRUE AND CORRECT.
    BY ENTERING MY NAME BELOW, I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS AGREEMENT AND I REPRESENT THAT BY SUBMITTING THIS DOCUMENT I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL TERMS HEREIN. I UNDERSTAND THAT A COPY OF THIS CERTIFICATION IS AS VALID AS THE ORIGINAL
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
  • PLEASE MAKE A COPY OF THE FRONT AND BACK OF INSURANCE CARD{S) AND SEND TO: 1.434.260.1131 or cindy@cindylernercounseling .com
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