Appointment of representative / Authorization of representation

I hereby authorize my Insurance Company to pay by check made payable and mailed directly to: FAST LAB TECHNOLOGIES, LLC for the medical and surgical benefits allowable, and otherwise payable to me under my current insurance policy, as payment toward the total charges for the services rendered. I understand that as a courtesy to me, Fast Lab Technologies, LLC will file a claim with my insurance company on my behalf. However, I am financially responsible for, and hereby do agree to pay, in a current manner, any charges not covered by the insurance payment. If it is necessary to file a formal collection action, I agree to pay all costs, including reasonable attorney’s fees incurred by Fast Lab Technologies, LLC in the collection of the outstanding fees. Actual Plan Benefits cannot be determined until the claim is received by your insurance company and is based upon their determination of medical necessity. The information received from the above stated is not a guarantee of payment.

I, [patient], appoint Fast Lab Technologies LLC., to act on my behalf in connection with any claim for coverage or benefits identified in this case, including receipt of any approval(s) or authorization(s) that are required before medical service(s). I authorize my representative to receive any and all information related to this case that is provided to me and to provide any information to the health plan in relation to the disputed claims, approvals, or authorizations. This information may include a diagnosis (name of illness or condition), claims, doctors and other health care providers and financial information (like billing and banking). I also understand that I may revoke (or cancel) this approval at any time. I understand that I cannot cancel this approval when this form has already been used to disclose information.

I have read the contents of this consent. I understand, agree, and allow Fast Lab Technologies LLC. to use and release my information as I have stated above. I also understand that signing this consent is of my own free will. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Fast Lab Technologies LLC.

I understand that my withdrawal of this approval will not affect any action taken before I do so. I also understand that information that’s released may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this consent.