BILLING AUTHORIZATION
CONSENT TO COLLECT & EXCHANGE PERSONAL INFORMATIONPersonal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by your insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering your group benefits plan, including the investigation of fraud and/or plan abuse.AUTHORIZATION & CONSENTI authorize HabitNu to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or administrator and their service provider(s) for the above purposes. I authorize the insurer and/or plan administrator and their service provider(s) to:
• Use my personal information for the above purposes.
• Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs relevant for the above purposes.
• Exchange personal information concerning any claims submitted with the plan member or person acting on behalf of the plan member.
• Exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original and may remain in effect for the continued administration of the group benefits plan.DIRECT BILLING POLICYI authorize HabitNu to bill my insurance company directly. I understand that HabitNu will bill the insurance company after the service is provided. I authorize the payment to be directly paid to HabitNu and I will be personally liable for any outstanding balance not covered by my insurance company. I will notify HabitNu if the payment from the insurance company is paid directly to my account. I understand that if for any reason HabitNu does not receive payment within 30 days of the service date, I will be responsible for the payment.
