(888) 330-7295

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Dear Member,
Thank you for sending the Balance Bill you received from your healthcare provider. It is very important you continue to send us ALL correspondence you receive from them. Your Health Benefit Plan provides for free representation for you against collection efforts for these medical expenses.
Your provider has already been paid fair and reasonable reimbursement for the medical care you received, described in the Explanation of Benefits (EOB).
Attached are two (2) documents for you to sign and send back to us:
1. CLAIM DOC‐ MEMBER AUTHORIZATION AGREEMENT This allows Claim DOC to act on your behalf in this specific matter.
2. HIPAA AUTHORIZATION
This allows Claim DOC access to your medical billing records.
Please immediately sign and date both documents and send them back through your mobile app.
In addition to your signature, please note where you must provide your name and the provider name as well. If you have any difficulty, please call a ClaimDOC Member Advocate at 1‐(888) 330‐7295.
Thank you!

CLAIM DOC - MEMBER AUTHORIZATION AGREEMENT. This CLAIMDOC-MEMBER Authorization Agreement (“Agreement”) is entered into by
(“Member”) and CLAIM DOC, LLC (“CLAIM DOC”), a Florida limited liability company and sets forth the terms and conditions upon which CLAIM DOC will provide service(s) to Member for the resolution of balance bill(s) related to medical services received on specific date(s) of service by Member at (“Provider”), including any collection efforts transferred by Provider to a collection agency.
Member authorizes CLAIM DOC to negotiate certain medical bills from Provider which is a hospital and/or medical facility whose medical bills were covered, in part, by Member’s health benefit plan (“Plan”).
This Agreement does not include any authorization by the Member for physician bills or other medical bills that were not submitted to or not paid by the Plan. This Agreement does not establish an attorney-client relationship between the member and CLAIM DOC.
CLAIM DOC’s legal fees and expenses for providing this service described above will be paid by the Plan once the Member provides informed written consent to this arrangement as evidenced by the Member’s signature below.
The Member is not financially responsible for legal fees or expenses incurred for services provided pursuant to this Agreement.
Member acknowledges and agrees that, if not already paid, the Member may owe a co-pay, co-insurance and/or deductible amount to the Provider as reflected on the Explanation of Benefits document(s) related to the medical bill(s) at issue.
Member acknowledges and agrees that any outstanding co-pay, co-insurance and/or deductible amount owed to the Provider will be immediately paid by the Member, or, immediate arrangements made with the Provider for payment.
Member acknowledges and agrees that all further correspondence and balance bills from the Provider related to this specific medical service(s), including notices of collection efforts will be immediately sent by fax to CLAIM DOC.
CLAIM DOC is hereby authorized to communicate on behalf of Member and engage, if necessary, outside attorneys and/or law firm(s) to represent the interests of the Member or to act on behalf of the Member directly. Any such outside attorneys and/or law firm(s) that are retained by CLAIM DOC to participate in the representation of the Member shall also be bound by this Agreement. The Member is not financially responsible for legal fees or expenses to any attorney or law firm retained by CLAIM DOC to participate in the representation of Member for the services described in this Agreement.
Member acknowledges that some outside attorneys and/or law firms(s) engaged to represent the interests of the Member may require a separate Authorization Agreement to be signed and provided by the Member.
As it relates to medical care that is the subject of this Agreement, reimbursement to the Provider has been calculated based on the Allowable Claim Limit and other provisions of the Member’s applicable Plan.
The Provider may claim that the Member, the Member’s Plan and/or the third-party administrator owe additional payment to the Provider. It is the position of CLAIM DOC that the Provider has been paid fair and reasonable reimbursement for the medical care and services rendered to Member as described in the Explanation of Benefits for the medical care at issue.
Although Member has the option to appeal the payment determination made by Member’s Plan, Member hereby acknowledges that CLAIM DOC does not intend to pursue such appeal on behalf of Member.
If Member wishes to pursue such an appeal to the Member’s Plan, Member may opt to do so without the assistance of CLAIM DOC. Member’s Plan provides a procedure for appeal directly by the Provider at issue.
CLAIM DOC will encourage the Provider to appeal to the Plan for additional payment.
The Member shall have the right to terminate and discharge this Agreement with CLAIM DOC at any time. The termination or discharge of CLAIM DOC must be in writing. In such event, the Member authorizes CLAIM DOC to make and retain a duplicate copy of the Member’s file. In addition, the Member acknowledges and agrees that CLAIM DOC may withdraw from providing service to the Member, at any time, upon written notice.
This Agreement correctly sets forth CLAIM DOC’s and Member’s understanding of the scope of the services to be rendered by CLAIM DOC. No variance, change, modification or augmentation of this Agreement shall be effective unless and until confirmed in writing, signed by CLAIM DOC and Member, and making express reference to this Agreement. This document embodies the whole agreement of the parties.
Nothing in this Agreement and nothing in CLAIM DOC’s statements to Member will be construed as a promise or guarantee about the outcome of the matter. CLAIM DOC makes no such promises or guarantees. CLAIM DOC’s comments about the outcome of the matter are expression of opinion only. There are no promises, terms, conditions or obligations other than those contained herein, and this contract shall supersede all previous communications, representations, or other agreements, either verbal or written, between CLAIM DOC and the Member.
Member acknowledges that he/she has the right to independent counsel and may seek the advice of counsel at Member’s own expense prior to entering into this Agreement. By signing below, Member acknowledges and agrees to have read and fully understood the entirety of this Agreement. If signed electronically, Member agrees that the electronic signature, whether digital or encrypted, is intended to authenticate this writing and to have the same force and effect as a manual signature.
Member authorizes John Steuterman to speak on his/her behalf with Claim DOC.
(enter “NONE” if no other family member) This Agreement is hereby agreed to and entered by Member on:
DATE: 2018-08-06
MEMBER SIGNATURE:


MEMBER BEST TELEPHONE NUMBER: 5156643788 MEMBER EMAIL: jjsteuterman@gmail.com PATIENT ACCOUNTS MANAGER & COMPLIANCE OFFICER
Re: HIPAA AUTHORIZATION
John Steuterman, undersigned Member/Patient Account No.John Steuterman .
I,John Steuterman , hereby authorize Claim DOC, LLC, to act on my behalf in the matter referenced above.
Please direct all future correspondence directly to Claim DOC, LLC at:
Claim DOC, LLC
100 SW Albany Avenue
Stuart, FL 34994
Phone: (888) 330‐7295
Furthermore, since it is necessary for ClaimDOC to see, use, and disclose my "Protected Health Information"
(or "PHI", as defined in 45 CFR § 160.103, which is part of the Standards for Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164, subparts A and E, (the "Privacy Standards") set forth by the U.S. Department of Health and Human Services ("HHS") pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended("HIPAA")),I also authorize the applicable Facility/Hospital/Provider to release my PHI, my electronic PHI (and all related medical, treatment, diagnostic and accounting records) to and discuss the same with ClaimDOC.
This authorization is given for the purpose of resolving all of my medical bills with your facility, including any agents or entities for which you assign this claim and associated alleged debt.
This authorization expires upon the resolution of my medical bills with your facility.
I understand by releasing this information, my PHI and electronic PHI may be disclosed by ClaimDOC to other individuals or entities and no longer protected by federal privacy regulations.
I understand I have the right to refuse to sign this authorization, and my refusal to sign does not (and will
not) affect my ability to obtain treatment or payment or my eligibility for benefits.
I understand I may inspect or copy the PHI and electronic PHI to be used or disclosed under this authorization.
I understand I have the right to revoke this authorization at any time and understand my revocation will be effective following my written notice to the applicable Facility/Hospital/Provider’s Business Office, with a copy to the Compliance Officer.
I understand that my revocation will not apply to actions taken by your facility prior to the date my written request to revoke this authorization is received by the Business Office or Compliance Officer, as applicable.
In addition, this letter hereby revokes any previous HIPAA or other medical authorizations that would enable the applicable Facility/Hospital/Provider to use, disclose or otherwise disseminate any of my confidential medical records and/or PHI, to any third party other than my attorney, my health benefit plan, or the third-party administrator of my health benefit plan.
Thank you,
Signature:
Date:

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