 I,
, authorize H.H.C.
Group and its
representatives to receive, disclose, utilize and discuss my personal health
information for the purpose of obtaining a reduction on my medical claim. If I
am not the patient but the parent or legal guardian of the patient, or the
estate representative, I authorize the release of the patient’s medical records
to H.H.C. Group
for the purpose stated above. I understand that
H.H.C. Group
may need to forward this Personal Health Information Authorization to the
provider in order to discuss my medical claim. Furthermore, my initials at the
close of this statement, indicate my
acceptance of: I. HIPAA Authorization and Release; the II. Consumer
Agreement, Payment Authorization, & release; and III. Preauthorization of
Payment. I also understand that I will need to sign and return to
H.H.C. Group the
HIPAA Authorization and Release located at the end of this page.
By
initialing below, I acknowledge that I am 18 years or older, and that I
authorize H.H.C. Group
to negotiate the medical claim that I submit. I agree to accept the settlement
that H.H.C. Group
achieves as final settlement of the medical bill. I understand and agree that
I will pay H.H.C. Group
a fee equal to 35% of the savings.
If
I am not the patient but the parent or legal guardian of the patient, or the
estate representative, I have authority to enter into this binding Consumer
Agreement and Release and agree to accept the negotiation on the patient’s
behalf.
I
will provide H.H.C. Group
with my credit card information and I agree that
H.H.C. Group may preauthorize the
credit card to assure that there are sufficient credit or funds to meet all
obligations proposed by this transaction. This will include payment of the
discounted claim liability to the provider and a fee of 35% of the
savings to H.H.C. Group.
I
release H.H.C. Group
and its officers, directors, members, agents, and employees from any and all
claims relating to the contemplated transaction, and to indemnify and hold
H.H.C. Group
harmless
from any and all claims asserted by me or any third party arising out of or
relating to the transactions authorized by me upon acceptance of this Consumer
Agreement and Release.
By
initialing below, I preauthorize payment of up to 95% of the medical bill I am
submitting to H.H.C. Group
and H.H.C. Group’s
fee. If H.H.C. Group
is successful in reducing the medical bill (claim), I
authorize H.H.C. Group
to provide this payment information to the provider. I understand
and agree that the provider or H.H.C.
Group will then charge the reduced
claim amount to the credit card that I provide, and that
H.H.C. Group will
charge its fee (35% of savings) to the same card. I understand that the reduced
claim and H.H.C. Group’s
fee will total less than the amount I owe or there will be no charges to the
card.
Please Download this form, complete, sign, and email or fax to
consumer@hhcgroup.com or (301) 963
9431.
WARNING: Failure to do so will resulted in delay of your application process.
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