SLEEPSOMATICS CLOSED EFFECTIVE APRIL 2023. SLEEPSOMATICS NO LONGER ACCEPTS ORDERS FOR SLEEP TESTING.

SleepSomatics Terms of Service

SSDC Service(s) Consent

PT acknowledges and agree that the purpose of this Agreement is to establish, provide, fulfill, bill and process insurance claims relating to his or her ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) [CPT] or [HCPCS] 95800, 95805, 95806, 95810, 95811, 94660, 99244, 99211, 99212, 99213, 99214, EO601, EO470, EO471, EO562, A4604, A7030, A7035, A7034 A7037, A7038 (individually and collectively, the "Service(s)"). 

PT gives his or her informed consent and authorizes SSDC to confirm, provide, bill and process insurance claims relating to SSDC Service(s). 

PT authorizes photocopies of this Agreement to be considered as valid as the original.

As a courtesy to PT, SSDC will, at its sole discretion, submit claims to PT's primary insurance provider and/or Medicare (collectively, the "Provider") on PT's behalf for SSDC Service(s).

PT understands and acknowledges that PT is solely financially responsible (without limitation) for immediately and completely paying any remaining amounts and balances, including any balance due amounts unpaid relating to SSDC Pre-service Quote(s) specifically involving SSDC Service(s) and PT and/or involving PT’s insurance(s) without limit including benefits delayed or denied involving Provider(s) in the unexpected event Provider delays or denies claim(s) SSDC submit on PT’s behalf.

PT must furnish SSDC all insurance information necessary to file and complete PT’s insurance(s) claim(s). PT must immediately notify SSDC of any change or loss of PT’s insurance(s) without limit including all related coverage(s) during the term of this Agreement.

PT authorizes his or her Provider(s) benefits be paid to SSDC for Service(s) performed or provided by SSDC involving PT and authorizes any holder of medical information about PT be released to SSDC (or any third party responsible) for payment(s) in full, without limit specifically including any information necessary to determine benefits payable or obtain payment(s) involving Provider(s) for SSDC Service(s) provided to PT. 

PT agrees to forward and deliver to SSDC, without delay, any payment made directly to PT for all such Service(s) SSDC provides to PT.

SSDC cannot and does not assume responsibility for any of the requirements involved with processing or obtaining insurance(s) coverage(s), without limit including Provider(s) policies or coverage(s) conditions or limitations, rules or regulations, plan specific criteria or determinations , involved with any PT insurance(s) or Provider(s) related claim(s). 

PT must pay all amounts and balances due under this Agreement. Amounts due under this Agreement include SSDC Pre-service Quote(s) involving SSDC Service(s) and PT. Without limit, amounts and balances due under this Agreement may or may not involve and/or include Provider(s) related deductibles, coinsurance(s) and copayment(s). SSDC cannot and does not guarantee coverage(s) or payment(s) by any insurance(s) and/or involving any related insurance(s) claim(s), without limit, as it relates to or in anyway involves or includes insurance(s) or Provider(s).

PT agree, acknowledge, and accept that Provider(s), at their sole discretion, may at any time, contract with one or more third party health or medical related authorizations administrators to confirm, approve or deny PT insurance(s) or coverage(s) for or involving SSDC Service(s) [without limit specifically includes any related health benefit(s) plan(s)]. PT accepts that any such authorization(s) by or involving Provider(s) is most often a confirmation of medical necessity only and does not confirm or deny any plan limitations or conditions that may or may not apply to PT’s health benefits or coverage(s). PT accepts that Provider(s) can, at any time, at their sole determination and discretion, apply health plan or coverage conditions or limitations for any given claim and that PT’s insurance(s) may or may not cover all, part or none of the claims SleepSomatics submit on PT’s behalf involving SSDC Service(s) without limit involving or including Provider(s).

SSDC may, at its sole discretion provide PT with Pre-service Quote(s) that provide Patient Payment Responsibilities involving SSDC Service(s). SSDC provides Pre-service Quote(s) to inform about out-of-pocket costs PT is responsible to pay SSDC before PT schedule or complete any SSDC Service(s). SleepSomatics may or may not, in its sole discretion, extend Pre-service Quote(s) to PT. SSDC Pre-service Quotes may or may not involve or include Bundled Service Plan(s). SSDC Pre-service Quote(s) for Bundled Three-Night Home Sleep Apnea Test(s) and Bundled Three-Night Home Limited Channel Test(s) include the sleep testing device together with all of the supplies and apparatus necessary to complete an all-inclusive Sleep Study Protocol. PT is responsible to pay SSDC in full the quoted Patient Payment Responsibility amount(s) at the time PT accepts an SSDC Pre-service Quote. For PT accepted SSDC Pre-service Quote(s) SSDC does not bill PT after the Service(s) Date(s) for other or added amounts, charges or billings. PT is responsible for payment in full to SSDC prior to the Date(s) of Service(s) for PT accepted SSDC Pre-service Quote(s).

Where applicable PT is responsible for PT related insurance(s) and/or Provider(s) related claims not covered or that SSDC is not paid for by PT’s insurance(s). SSDC cannot and does not guarantee any time frame involving the submittal(s) or processing of PT’s insurance(s) or claim(s) by or relating to SSDC. Assignment of benefits of third-party does not relieve PT's obligation to ensure full payment under this Agreement. SSDC does not offer billing of tertiary payers or Provider(s). SSDC may or may not provide documentation for PT to submit related insurance(s) claim(s) on his/her own. SSDC cannot and does not accept any insurance related claim involving DATA ISIGHT. Further to this, SSDC rejects all Provider(s) claim(s) processing that use, or is based upon, or is delegated to, or handled by/from, or in any way processed or paid or reimbursed involving DATA ISIGHT.  

PT represents and warrants that said PT signatures bearing PT's name are made by PT and that PT is legally competent to execute this Agreement between PT and SSDC or the duly authorized representative of PT is legally authorized to execute this Agreement on PT's behalf.

PT acknowledges that SSDC has not assessed PT’s home environment and therefore assumes no responsibility for the safety of any procedures or equipment PT takes to the home environment or PT’s usage of any procedures or equipment within PT’s home environment or anywhere else PT may travel to or use said procedures or equipment. PT is solely responsible for all legal, medical, financial, and other responsibilities, laws, regulations, and other contemplating the proper, safe, and legal use of all procedures and equipment under this Agreement.

PT authorizes SSDC to provide, at PT’s ordering or treating healthcare provider’s direction, SSDC Service(s). PT agrees that SSDC and its affiliates, agents, or assigns, shall not be liable for any acts or omissions related to the Service(s) provided by SSDC relating to PT in accordance with PT’s ordering or treating healthcare provider's orders.

PT agrees and requests that payment of authorized healthcare benefits be made on PT’s behalf directly to SSDC for Service(s) provided by SSDC relating to PT. PT authorizes and assigns directly to SSDC all payments and benefits otherwise payable or available to or without limit involving PT, insurance(s) and Provider(s), and/or to which PT is otherwise entitled, under or pursuant to terms of any government, private, employer, group, or other health insurance program or plan or Provider(s). PT authorizes photocopies of this Agreement to be considered as valid as the original without exception.

Where applicable PT agree, acknowledge, and accept that PT is obligated to personally pay, in full and immediately upon receipt of bill, the difference between the amounts PT’s insurance benefits or insurance coverage pays to SSDC and what SSDC can lawfully charge for Service(s) provided by SSDC. In the event that SSDC notifies PT that any claims for payment on PT’s behalf were refused by a third party payer for any reason (involving Provider(s) and including, but not limited to, PT’s failure to qualify for Service(s) and/or related services provided by SSDC, lack of coverage involving PT’s insurance(s), or PT failure to provide complete and accurate information needed to submit claim(s) and be paid in full by said insurance(s)), then PT will, immediately upon and/or after SSDC submission of statement or demand for amounts due by PT, submit full payment to SSDC for Service(s) provided by SSDC involving PT under this Agreement. PT payment shall be made to SSDC immediately upon receipt of said balance due statement or demand and shall not exceed fifteen (15) days from receipt of said balance due statement or demand. Amounts due under SSDC Pre-service Quote(s), may or may not include, without limit, deductibles, coinsurance or copayment amounts involving private third party insurance(s) and/or contracts. SSDC Pre-service Quotes are generally due at or before the date SSDC provides Service(s). In the event SSDC does not collect all amounts due by/from PT up front in advance of SSDC providing Service(s), then PT agree that PT is and will continue to be obligated to immediately pay in full all such amounts due without limit including Patient Payment Responsibilities and any applicable deductible(s), coinsurance(s) or copayment(s) immediately upon receipt of SSDC balance due statement or demand and shall not exceed thirty (30) days from receipt of said balance due statement or demand. PT agrees and acknowledges that SSDC may refuse further, other or added Service(s) to PT or on PT’s behalf until any and/or all such outstanding balance(s) due are paid in full. SSDC may decline to produce medical records or documentation until all outstanding balance(s) due by PT are paid in full (as permitted by law). PT agrees and acknowledges that failure to remit full repayment within forty-five (45) days to SSDC of all monies due by PT to SSDC will be deemed in default. PT agrees and acknowledges that SSDC may use all commercial options available for seeking payment in full of all balance(s) due or owing by PT within sixty (60) days of all such payments due, which may include the use of third-party collection agencies (where applicable). SSDC is not and will not be liable for the disclosure of PT's protected information including PT’s protected health information to said third-party companies used for obtaining payment of any outstanding amount or balances due or owing by PT nor any related medical costs or treatment interruptions PT may incur (and the related health risks to untreated sleep disorders) due to said SSDC Service(s) discontinuation.

DISCLAIMER OF WARRANTIES / LIMITATION OF LIABILITIES: EXCEPT WHERE STATED OTHERWISE, SSDC MAKES NO EXPRESS OR IMPLIED REPRESENTATION OR WARRANTIES CONCERNING SERVICE(S) PROVIDED AND DISCLAIMS, WITHOUT LIMITATION, ANY IMPLIED WARRANTY OF MERCHANTIABILITY OR FITNESS FOR A PARTICULAR PURPOSE, TO THE EXTENT ALLOWED BY APPLICABLE LAW. MOREOVER, SSDC SHALL NOT BE RESPONSIBLE FOR ANY SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES CAUSED BY SERVICE(S) PROVIDED BY SSDC, EVEN IF SSDC HAS KNOWLEDGE OF THE POSSIBILITY OF SUCH POTENTIAL LOSS OR DAMAGE.

SSDC perform Service(s) in accordance with the ordering or treating healthcare provider's orders and standards published by the American Academy of Sleep Medicine (AASM), the Centers for Disease Control (CDC), the Centers for Medicare Services (CMS), the interpreting physician or specialist, and the SSDC Medical Director (when applicable).

PT understands any PT questions or concerns regarding SSDC Pre-service Quotes, SSDC Service(s), PT's insurance(s) or coverage(s), or that involve quoted amounts or balances due, PT must contact SSDC during daytime administrative hours before SSDC performs Service(s) and specifically before the PT’s scheduled Date(s) of Service(s). PT agrees to promptly pay all such payments or outstanding amounts due from PT to SSDC not later than the date of PT's Service(s) unless prior financial arrangements have been established and approved by SSDC.

Member Authorization Form for a Designated Representative to Appeal a Determination

PT HEREBY AUTHORIZE SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") TO REJECT AND/OR APPEAL INSURER'S DETERMINATION CONCERNING PT’s ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) [CPT] or [HCPCS] 95800, 95805, 95806, 95810, 95811, 94660, 99244, 99211, 99212, 99213, 99214, EO601, EO470, EO471, EO562, A4604, A7030, A7035, A7034 A7037, A7038 (individually and collectively, the "Service(s)") on PT’s behalf, as PT’s Designated Representative, and, as part of the appeal, PT hereby authorize all of PT INSURANCE'S, without limit specifically including PT’s related Provider(s), in any related decision letter and in connection with the processing of any necessary appeal(s), to communicate with PT Designated Representative in all aspects of such appeal(s).

PT understands and agrees these communications may contain the following: All medical and financial information contained in PT insurance file involving SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") including and relating to PT’s ordering or treating healthcare provider-ordered sleep diagnostic appointment which may include procedures, diagnostics, equipment, or other such as (but not limited to) [CPT] or [HCPCS] 95800, 95805, 95806, 95810, 95811, 94660, 99244, 99211, 99212, 99213, 99214, EO601, EO470, EO471, EO562, A4604, A7030, A7035, A7034 A7037, A7038 (individually and collectively, the "Service(s)") in connection with and in the case of any such determination which is being appealed. PT understands and agrees this information is privileged and confidential and will only be released as specified in this authorization, or as required or permitted by law. This authorization is valid for a period of three years, or the time it takes for SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") to appeal for correct payment under PT’s Insurance Plan(s). 

SSDC Additional Disclosures 

PT is solely responsible for notifying SSDC in writing of changes to his/her contact information, with said notification being timely delivered to and received by SSDC. 

SSDC is not responsible for locating PT in the case s/he provided incorrect contact information in this Agreement or whose contact information changed after this Agreement’s execution. 

PT is responsible for furnishing SSDC with all applicable insurance information necessary to obtain payment in full for SSDC Service(s) without limit including diagnostic services, equipment, supplies, and/or accessories. 

PT is responsible for assuming sole and full responsibility for SSDC Pre-service Quote(s) or where/when applicable all charges and costs not covered by Provider(s) without limit including PT’s insurance(s), deductibles, coinsurance(s) and copayment(s). PT is fully 100% responsible for settlement in full of any outstanding balances and amounts due under this Agreement. 

PT is responsible for contacting SSDC by telephone at (512) 323-9253 to timely schedule, modify, or cancel appointments and acknowledges and understands that there may be additional fees for “no-shows” or same-day cancellations for procedures, diagnostics, and confirmed appointments.

PT is responsible for immediately notifying SSDC by telephone at (512) 323-9253 if PT has: 

Any change in PT’s physician’s orders or prescription; 

Any change or loss in insurance(s) or related coverage(s);

Any change in PT's contact information, whether permanent or temporary; 

Any infectious diseases or illness PT has or may suspect s/he have prior to or during any Service(s) SSDC provide to PT.

SSDC offers flexible appointment times and schedules.

SSDC does not offer walk-in services. 

All SSDC services are available by appointment only. Appointment availability is limited based upon a first-come, first-serve basis. SSDC makes no guarantee as to appointment availability.

PT Acknowledge and accept the contagious nature of COVID-19 (Coronavirus) and other communicable diseases and PT voluntarily assume the risk that any PT may be exposed to or infected by COVID-19 (Coronavirus) or other such communicable diseases by attending or completing an appointment(s) in person at or involving SSDC and that any such PT exposure or infection may result in personal injury, illness, disability, or death, and further, PT understand that any such risk of exposure or infection may result from the actions, omissions, or negligence of PT and others, including, but not limited to, other patients or SSDC staff without limit including any employees. PT voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any exposure to COVID-19 or other communicable diseases that PT may experience in connection with any PT attending or completing an in person appointment(s) at or involving SSDC.

PT has the right to considerate and respectful service and to obtain service without regard to race, creed, national origin, gender, age, sexual orientation, disability, illness, veteran status, religious affiliation, or any other protected class under the law. 

SSDC reserves the right to refuse any of its Service(s) to anyone if deemed necessary by SSDC at its sole discretion. 

SSDC reserves the right to refuse any of its Service(s) to anyone if SSDC deems necessary, at its sole discretion, involving any PT that requires Service(s) that SSDC is unable to adequately provide. 

PT has the right to confidentiality of all information pertaining to PT’s medical care and service in accordance with this Agreement. 

PT has the right to a timely response to his/her request for service (depending upon the service requested) in accordance with this Agreement. 

PT has the right to select another provider of his/her choice and to make informed decisions regarding PT’s care including the right to agree or to refuse any part of SSDC’s plan of service or plan of care for PT in accordance with this Agreement.

PT has the right to be told what service will be provided, how, and to voice grievances.

SSDC observes thorough PT grievance and complaint procedures to effectively resolve problems that may arise. Any PT that has a concern, may call SSDC by telephone at (512) 323-9253, or may write to SSDC at 2211 W Parmer Lane, Austin Texas 78727 ATTN: Medical Director.

SSDC Consent for Use and Disclosure of PT Health Information – HIPAA and Privacy Notice

PT has the right to refuse to sign any SSDC Agreement including, but not limited to, this consent. Such refusal may mean that SSDC may decline to provide or continue providing Service(s) to PT.

SSDC may employ any or all of the following options to contact PT: telephone calls, voicemail messages, postcards or letters via postal or other third party mailings or deliveries, SMS text messages, and/or emails. 

PT agrees with and gives SSDC authorization and permission and directs SSDC to leave PT messages when attempting to contact PT at the phone number(s), email addresses, postal mailing addresses, and any and all other contact options provided by PT to SSDC. These messages may or may not contain HIPAA protected private information regarding procedures, diagnostics, tests, appointments, insurance, or other. These messages may be left on voicemail (cell, home, work, etc.), by text message, by email, via internet based applications or other message delivery services. PT releases SSDC from any and all liability arising out of or resulting from someone else overhearing or in some way intercepting messages left by SSDC for PT. PT will notify SSDC if there is contact information or methods PT does not want used by SSDC when attempting to contact PT. PT has the option to decline one or all of the above listed communication methods by evidencing their choice with written letter signed by PT and delivered or mailed to SSDC.

PT agrees with and consents to SSDC using and disclosing his/her protected information or PT’s protected health information in order to provide Service(s), to collect payment, and to care for PT’s sleep related health. This may include (but shall not be limited to) disclosure of PT’s protected health information to third-party companies for the purpose of collection of payments or monies owed, including but not limited to Provider(s) and without limit including any related PT insurance(s), banks or credit card companies, third-party collection agencies, and/or credit reporting agencies.

A copy of the SSDC Privacy Notice and Patient Bill of Rights may be found and printed from SSDC's website at www.sleepsomatics.com. These notices provide a detailed description of how SSDC may use PT protect information or PT’s protected health information. PT has the right to abstain from signing any SSDC Agreement including, but not limited to, this consent until s/he has read these notices. Such refusal may mean that SSDC may decline to provide or continue providing Service(s) to PT. SSDC reserves the right to change our privacy practices as described in our Privacy Notice.

PT is responsible to file a new Communication Authorization with SSDC any time PT’s household situation changes. SSDC is not responsible for unwanted communications involving PT if at any time PT fails to notify SSDC about changes relating to PT’s household situation. SSDC considers PT’s communications related permissions current unless or until such time PT notify SSDC about changes and request changes directly with SSDC. PT has the right to revoke PT’s communications related permissions at any time. To revoke communications related permissions, PT must deliver, fax or mail written notice of their revocation to SSDC. Such PT revocation will not apply retroactively. PT revocation may mean that SSDC may decline to provide or continue providing Service(s) to PT.

SSDC Authorization to Release PT Medical Records

PT hereby authorizes the use or disclosure of PT reports, charts, data, and other information from the diagnostic and health records received, created, compiled, or otherwise in the possession of or resulting from or in connection with SSDC Service(s) including, but not limited to, physician-ordered diagnostic sleep study or studies with or involving other diagnostic providers, physicians, or DME companies (collectively, the "Record"). PT directs his/her Record to be immediately furnished to SSDC as required by SSDC to complete the Service(s) or fulfill any orders or directives made by PT’s physician as part of SSDC Service(s) for or involving PT. 

PT understands and agrees that his/her Record may only be released at PT’s specific direction, and PT directs such release to SSDC. Any other use of this information without PT’s written consent is prohibited.

PT understands and agrees that PT has a right to revoke this authorization at any time. PT understands that if PT revokes this authorization, PT must do so in writing and present his/her written revocation to the individual or organization releasing the information. PT understands and agrees that the revocation will not apply to information already released in response to this authorization. PT understands and agrees that any PT revocation will not apply to Provider(s) without limit including PT’s insurance(s) when the law provides such insurance(s) with the right to contest or deny a claim under PT’s policy. Unless otherwise revoked, this authorization shall expire upon completion of this request.

PT understands and agrees that authorizing the disclosure of his/her Record is voluntary. PT understands that s/he may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. PT understands that any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not be protected by federal or state confidentiality or privacy laws. PT understands s/he can contact SSDC during daytime administrative hours at (512) 323-9253 with questions about disclosure of his/her Record. PT understands and agrees that the information in PT’s Record may include information relating to sexually-transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), behavioral and/or mental health services, and treatment for substance abuse.

PT understands and agrees that his/her Record may contain reports, diagnostic and or therapy results, and/or notes that only a physician can interpret or diagnose. PT understands and is advised to contact his/her physician regarding the entries made in PT’s Record to prevent PT misunderstanding of the information contained in his/her Record. PT releases and holds harmless SSDC from any and all liabilities arising out of or resulting from any misinterpretation of the information contained in PT’s Record or as a result of PT not contacting his/her physician for the correct interpretation.

PT Assignment of Insurance Benefits, PT Legal Authorized Representative Appointment, PT Authorization to Release Information

PT HEREBY ASSIGN all applicable health insurance benefits and all rights and obligations that PT and any PT dependents have under PT health plan(s) to EL’Lucre Management Corp DBA SleepSomatics [together, doing business as SleepSomatics or SleepSomatics Diagnostic Center, SleepSomatics LP (TIN 20-4601197 NPI 1538251202) and EL’Lucre Management Corp (TIN 52-2416115 NPI 1013191386)] whose physical location is 2211 W Parmer Ln, Ste A, Austin, TX, 78727 and whose telephone number is (512) 323-9253 and whose fax is (512) 323-9254 (individually and collectively, "SSDC") for the purposes stated herein (collectively, the "Agreement") and SSDC representatives (hereinafter, “PT Authorized Representatives”) and PT appoint SSDC his/her authorized representatives with the power to, at its own discretion, do any or all of the following: (i) file medical claims with PT health plan(s), (ii) file appeals and grievances with PT health plan(s), (iii) institute any necessary litigation and/or complaints against my health plan naming PT a plaintiff in such lawsuits and actions if necessary (or SSDC as guardian of the PT if the PT is a minor); (iv_ discuss or divulge any of PT personal health information or that of PT dependents with any third party including PT health plan(s).

PT HEREBY CERTIFY that the health insurance information that PT provided to SSDC is accurate as of, and without limit subsequent to, the date set forth by PT signature in writing and or by electronic signature his/her agreement with/to SSDC published Terms of Service.

PT HEREBY CERTIFY understanding and agreement without reservation that PT is responsible for all amounts not covered by PT health insurance plan(s) without limit including co-payments, co-insurances, deductibles, and or regardless of any adjudication(s) by any PT health insurance plan(s).

PT HEREBY AUTHORIZE his/her Authorized Representatives, specifically includes SSDC and hereof related Agreement, to: (1) release any information necessary to PT health benefit plan (or its administrator) regarding PT illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of PT signature to be used to process insurance claims. This order by PT will remain in effect until revoked by PT in writing.

PT ERISA Authorization

PT HEREBY DESIGNATE, AUTHORIZE, AND CONVEY to his/her Authorized Representatives, specifically includes SSDC and hereof related Agreement, to the full extent permitted under law and under any applicable insurance policy and/or employee health care benefit plan and/or other health care plan: (1) the right and ability to act as PT’s Authorized Representative in connection with any claim, right, or cause of action including litigation against PT’s health plan(s) (even to name PT as a plaintiff in such action) that PT may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as PT’s Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as PT’s Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of services, without limit specifically includes SSDC Service(s), PT received from SSDC and, to the extent permissible under the law, to claim on PT behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. PT authorizes communication with SSDC and its authorized representatives by email and/or by electronic communications without limit including PT agreement by Electronic Signature. By signing by written form or an electronically completed signature, PT also understands that if SSDC does not have a contract with PT’s insurance plan(s), the fees for services, without limit specifically includes SSDC Service(s), will be at minimum no less than as they are listed on www.fairhealthconsumer.org. PT ALSO AGREE AND AUTHORIZE a photocopy of this PT ERISA Authorization hereof PT’s Assignment/Authorization shall be as effective and valid as the original.