Assignment Of Benefits
ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
TOGETHER WITH ERISA REPRESENTATIVE DESIGNATION
By checking the “assignment of benefits” box on my order form, I understand and agree that I am ultimately responsible to pay Genadyne Biotechnologies Inc. the balance due on my account for my breast pump and any supplies provided, and I authorize payment of any health insurance or medical plan benefits directly to Genadyne Biotechnologies Inc. for my breast pump and any supplies provided.
I hereby assign directly to Genadyne Biotechnologies Inc. all rights to payment and benefits and all legal and other health plan, ERISA plan, or insurance contract rights that I or my beneficiaries have under my / our applicable health plan(s) or health insurance policy(ies). This assignment includes, but is not limited to, a designation that Genadyne Biotechnologies Inc. may act on my / our behalf, as our representative or ERISA representative, as to any initial claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and / or payments that are due to Genadyne Biotechnologies Inc. as a result of their services rendered. Also Genadyne Biotechnologies Inc. may pursue all remedies to which I / we may be entitled, including legal action taken to pursue payment of my claim. This assignment and designation remains in effect unless revoked in writing, and a photocopy of my order form is to be considered as valid and enforceable as the original.