I understand that by signing this agreement, I authorize provision of products and/ or services to me by Get Well Now. I also understand that the products and services provided are prescribed by my physician and that it is necessary that I remain under the supervision of my attending physician during the course of my care.
I hereby authorize release to Amber Specialty Pharmacy any and all of my medical records pertaining to my medical history, services rendered, or treatments received from my physician(s) or hospital. In order to process insurance claims, I also hereby authorize Amber Get Well Now to furnish to my insurance carrier(s), any medical history, services rendered, or treatment needed. For more complete information, please review the Notice of Privacy Practices.
I authorize direct payment of insurance benefits by my insurance company to Get Well Now. In the event that my insurance carrier does not accept “assignment of benefits,” I understand that payments may be sent directly to me and that I am obligated to endorse, and will directly send such payments to Get Well Now for payment of my bill. It is my responsibility to notify Get Well Now of any changes to my insurance information. I understand that I am responsible to Get Well Now for all charges not covered by my insurance. I recognize that in the event that my insurance company, employer or any other third party payer refuses to pay the purchase price(s) of the items, or delays payment beyond 90 days of my receipt of items, or in the event that I have no insurance coverage or third party payer, that I will be responsible for said payments and will make prompt reimbursement within 30 days of notification by Get Well Now for invoiced charges.
