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Billing Authorization

CONSENT TO COLLECT & EXCHANGE PERSONAL INFORMATION

 

Personal 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.

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AUTHORIZATION & CONSENT


I 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:

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  • Use my personal information for the above purposes.

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  • 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.

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  • Exchange personal information concerning any claims submitted with the plan member or person acting on behalf of the plan member.

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  • 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.

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DIRECT BILLING POLICY


I 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.

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