Assignment of Benefits

I hereby assign to Parsley Medical, PLLC, and its affiliates, Parsley Medical PC, Parsley Medical Group FL PA, and Parsley Medical Group NJ PA(collectively, “Parsley Health”) all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any private or employer sponsored insurance for medical treatment rendered by Parsley Health. Parsley Health does not participate
in Medicare or Medicaid. The assignment will remain in effect until revoked by me in writing. I authorize the release of pertinent information necessary to process my medical claim. I also authorize direct payment to Parsley Health of all insurance or other employment benefits payable to me for such medical treatment. In the event an insurance payer or other payer pays me directly, I agree to immediately pay such amounts to Parsley Health.

I understand that my insurance or employer sponsored payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying Parsley Health for any and all amounts not paid by my insurance or employer-sponsored payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand that if my insurance or other coverage requires a referral, I am responsible for obtaining one prior to my appointment. In the event any collection action is necessary to collect amounts I owe to Parsley Health, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.

I certify that I have read and understand the foregoing and received a copy thereof. I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign and accept its terms on his/her behalf.

FINANCIAL RESPONSIBILITY AGREEMENT

Parsley Health, PLLC, and its affiliates, Parsley Medical PC, Parsley Medical Group FL PA, and Parsley Medical Group NJ PA (collectively, “Parsley Health”) committed to providing the best quality medical services (the “Services”). This Financial Responsibility Agreement (“Agreement”) outlines your financial responsibility in relation to receipt of the Services from Parsley Health.

PAYMENT OPTIONS

*Parsley Health accepts certain insurance plans in certain states, including some plans offered by Aetna, Blue Shield, UHC, Empire BCBS NY, HIP, Oscar,Cigna, UHC UMR, GHI, Healthfirst, Centivo. Please let Parsley Health know if you have medical insurance that you plan to use for payment of the Services and Parsley will confirm whether it accepts your plan. Parsley Health also offers a self-pay option for the Services. Please see the Self-Payment of Services section below for information on self-pay options.

OPTION A: INSURANCE

As a courtesy to its patients, Parsley Health is pleased to assist in the submission of medical insurance claims to insurance companies for payment. Currently, Parsley Health only participates with and bills for Aetna, Blue Shield, UHC, Empire BCBS NY, HIP, Oscar, Cigna, UHC UMR, GHI, Healthfirst, Centivo commercial health products in New York, Aetna and Blue Shield of California commercial health products in California, and certain additional states. Parsley Health does not participate in Medicare, Medicaid or any other Health Plan.

By click signing this agreement, you understand and acknowledge that:

• Your medical insurance policy, if any, is a contract between you and your insurance company.  It is your responsibility to know your benefits, and how they will apply to payment for the Services.
• It is your responsibility to confirm that the provider that you see at Parsley Health is a participating provider under your medical insurance policy.
• Your insurance company may not cover 100% of the costs and fees associated with the Services, and you will be responsible for payment of any remaining balance due for the Services, including without limitation, for paying copayments, deductibles, and any other costs and fees associated with the Services you receive that are not fully (or at all) covered by your insurance company.
• It is your responsibility to provide Parsley Health with appropriate and current medical insurance information, and to notify Parsley Health immediately upon any change in your medical insurance coverage to ensure efficient claims billing and payment. In the event that you fail to provide all necessary and current medical insurance information, you understand that your insurance company may deny payment of claims relating to the Services, and you understand that you may be 100% responsible for the costs and fees associated with the Services.
• It is your responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving the Services from Parsley Health. If your insurance company requires a referral and you do not have one, then you understand that you will be responsible for all costs and fees associated with the Services you receive.
• If your medical insurance requires a copay, the copay is required at the time the Service is rendered.

By click signing, you further hereby authorize payment of all medical insurance benefits which are payable to you under the terms of your medical insurance policy to be paid directly to Parsley Health for the Services rendered.

OPTION B: SELF-PAYMENT OF SERVICES

Services provided by Parsley Health that are not covered by medical insurance are 100% self-pay by our patients.

By click signing this agreement, you understand and acknowledge that:

• You are electing to purchase the Services which may or may not be covered by your medical insurance if you obtained similar services from a different provider.
• You are electing not to use a medical insurance policy benefit.
• You have been given a choice of the Services provided by Parsley Health, along with their costs.
• You have selected the Services and you are willing to accept full financial responsibility for payment of the Services.
• You have selected the Services for purchase from Parsley Health on a self-pay basis.  In other words, you have directed Parsley Health to treat your purchase of the Services as if you were an uninsured patient and you therefore agree to be 100% responsible for full payment of the listed price of the Services as set forth in the Fee Schedule below.