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Assignment of Benefits

I hereby assign to CopilotIQ Medical, P.A., and its affiliates, CopilotIQ, P.C. and Burton Hills Medical Services, P.C. (collectively, “Group”) 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 insurance payer, including Medicare, private insurance and any other health plan for medical treatment rendered by Group. 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 Group of all insurance benefits payable to me for such medical treatment. In the event an insurance payer pays me directly, I agree to immediately pay such amounts to Group.

I understand that my insurance payer may pay less than the actual bill for services. I acknowledge that I am still responsible for paying Group for any and all amounts not paid by my insurance payer, including non-covered charges and all copayments, coinsurance, and deductibles. I understand that if my insurance 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 Group, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.

I consent to receive online bills and Explanation of Benefits from CopilotIQ electronically. If you wish to obtain a paper copy of any such document or information, the paper copy will be mailed to you upon request at no cost. To request a paper copy of any such document or information, you may contact us 1-800-930-5144 or by email at info@copilotiq.com. You have the right to withdraw your consent at any time by choosing to resume paper delivery of your monthly bill statement. To elect to resume paper delivery of your monthly bill statement, please visit our website at www.CopilotIQ.com. After you successfully sign in, please navigate to where you may manage your statement delivery preferences, follow the instructions provided, and save your changes. In order to ensure that we are able to provide you with important notices and other information, you must update us with any change in your email address. To update the email address on your account, please visit our website at www.CopilotIQ.com. After you successfully sign in, please navigate to where you may change email address, follow the instructions provided, and save your changes. If you fail to update your email address and we receive a response that our email was undeliverable, the email that CopilotIQ is required by law to provide or make available to our members in writing will be deemed to have been received by you on the date the email was sent.

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 the above and accept its terms on his/her behalf.