This is to inform you that your insurance carrier may cover procedures or diagnostic tests that your doctor consider
necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any
appeal process necessary.
You understand that your Provider and/ or you may appeal any determination that a Benefit Agreement of Evidence of
Coverage. You may have the right to Independent Medical Review through DMHC.
Your signature on this form acknowledges that you agree to bear full financial responsibility for all service
The Services are not covered by your insurance carrier, or
The Services have not been otherwise approved for payment.