Please sign the required documents. Thank you.
ASSIGNMENT, REQUEST AND AUTHORIZATION
By signing below, I understand, request and authorize Express Relief, LLC., its assignees, and/or its agents to ship & supply medical supplies and/or devices, including TENS, EMS, or combo TENS/EMS unit, as well as TENS/EMS medical supplies for a 4-lead unit, every 2 months for at least 6 months or for the time period as prescribed by my physician or requested by me. I also authorize Express Relief, LLC, its assignees, and/or its agents to bill and submit claims for the following codes: A4556 electrodes, A4557 lead wires, A4611 batteries, A4558 conductive gel, EO731 garment electrode, A4595 tens supplies, as well as other HCPCS/CPT codes that coincide with the directions of my physician or per my request, including codes for the instruction & use of the equipment. I understand that Express Relief, LLC may use healthcare provider contractors and agents in order to fulfill such requests and requirements. I understand these supplies will be billed and delivered every 2 months for at least 6 months to receive the greatest results, unless otherwise indicated by me or my physician. Once supplies have been opened, they cannot be returned. I can cancel the supplies at any time by faxed request to 1-844-500-3972
I hereby authorize Express Relief, LLC, its assignees, and/or its agents to supply me with TENS/EMS supplies and or device(s) as prescribed by my physician. I hereby authorize you, my insurance company and/or attorney, to pay directly Express Relief, LLC (“Assignees”) such sums as may be due and owing Assignees for disposable supplies given to me, both by reason of accident or illness, and by reason of any other bills that are due Assignees, and to withhold such sums for any disability benefits, medical payments, No Fault benefits, or any other insurance benefits obligated to reimburse or form any settlement, judgment, or verdict on my behalf as may be necessary to adequately protect said Assignees, I hereby further give a lien to said Assignees any and all insurance benefits named herein and any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by Assignees. This is to act as an assignment of my right and benefits to extent of the Assignees supplies provided to me in accordance with state statute(s).
I hereby grant the release to and from Express Relief, LLC of any/all medical records ito process payment for supplies claims and/or processing of supplies. I authorize all health care providers, physicians, hospitals, medical staff and attorneys to furnish any and all information and medical records regarding me to Express Relief, LLC, including psychiatric, psychological and any mental health records. I authorize Express Relief, LLC to release any and all information and medical records regarding me, including psychiatric, psychological and any mental health records, to those parties that are necessary to process and/or collect from my insurance claim(s), and/or other claims related to my healthcare supplied & services.
In the event my insurance company obligated to make payments to me upon charges made by Assignees for supplies, refuses to make such payments, upon demand by me or Assignees, I hereby assign and transfer Assignees any and all causes of action that I might have or that exist in my favor against such company and authorize assignees to prosecute said causes of action either in my name or in Assignees’ name, and further I authorize Assignees to compromise, settle, or resolve said claim or cause of action as they see fit. In due, valid and good consideration I hereby indemnify and hold harmless Express Relief, LLC and its assignees harmless from any and all actions and/or claims in regard to the usage and outcomes from TENS/EMS equipment and/or all medical supplies & devices provided to me and its billing of payer(s). To avoid exhaustion of insurance benefits while Assignees pursue its right under this assignment, I direct my insurance company to set aside and place in escrow any disputed amount or reductions until the resolution of such dispute. I authorize Assignees to release any information pertinent to my case to any insurance company, adjuster, or attorney to facilitate collection under this Assignment, Lien, and Authorization. I hereby understand and acknowledge that Assignees comply and make every effort to comply with all national, state and local privacy act regulations and requirements and have read their privacy policies.
Please sign below acknowledge that you read and agree with our Privacy Practices
Personal Health Information Disclosure and Use (PHI) / Patient Privacy - Express Relief, LLC
Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.
If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing.
If denied, you can place a written statement in your records disagreeing with the denial of your request.
Those who want to sign on paper, then print and sign the PDF version at www.Express-Relief.com under "Print Form", complete it, sigh it, and fax it immediately to the number indicated on the App and Website and/or form. You affirmatively consent to the use of this electronic signature and have not withdrawn such consent, prior to consenting you:
1. I understand that I have the right or option to have this record provided or made available on paper or in nonelectronic form (this form is available for you to print or we can mail you a copy on your request, a printable format is available on our web www.Express-Relief.com. 2. Have the right to withdraw this consent to have the record provided or made available in an electronic form and of any conditions, consequences ( which may include termination of both parties' relationship) or fees in the event of such withdrawal 3. If you wish to withdraw this consent, please e-mail us at firstname.lastname@example.org 4. We may contact you via telephone, e-mail, US mail or other delivery method in order to update your electronic communication information in compliance with Federal guidelines, statutes and law. 5. After such consent, you may upon request, obtain a paper copy of an electronic record free of charge by printing this form on your computer or by requesting it from us. 6. Prior to consenting you understand that the hardware and software requirements to access and retain this electronic record is any computer which can access the internet and has a compatible web browser. 7. This electronic consent or electronic confirmation demonstrates that you can access information in the electronic Authorization form. 8. After such consent, if there is a change in the hardware or software requirements needed to access or retain electronic records creates a material risk that the you will not be able to access or retain a subsequent electronic record that was the subject of the consent, Express Relief provides the following: (i) provides you with a statement of (I) the revised hardware and software requirements for access to and retention of the electronic records, and (II) the right to withdraw consent without the imposition of any fees for such withdrawal and without the imposition of any condition or consequence that was not disclosed under these disclosures.
You are required to comply with all applicable laws in connection with your use of the App and Website, and such further limitations as may be set forth in any written or on-screen notice from Express Relief. As a condition of your use of the App and Website, you agree that you will not use the Website for any purpose that is unlawful or prohibited by this Agreement.
ELECTRONIC & TELEPHONIC COMMUNICATIONS
When you visit the Website, telephone Express Relief or send e-mail(s) to Express Relief you are communicating with Express Relief electronically or telephonically. You consent to receive communications from Express Relief electronically or telephonically. Express Relief will communicate with you by e-mail or telephonically. You agree that all agreements, notices, disclosures and other communications we provide to you electronically or telephonically satisfy any legal requirement that such communications be in writing.