Assignment of Benefits

Partner Laboratories: I hereby authorize Sameday Testing partner laboratories such as, Quest Diagnostics, Rume Lab and its affiliated receiving and/or performing laboratories (collectively herein, "Laboratory") and/or its authorized agents, to run the specified tests on my blood and other specimens/samples and agree to the terms and conditions. I understand that as a courtesy, Laboratory and/or its authorized agents will make every reasonable effort to obtain insurance reimbursement for ordered tests. I understand that I am making an assignment of my insurance plan benefits to Laboratory and/or its authorized agents. I also authorize the release of any information contained in my records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with the same. Bill to my insurance: I understand that if my insurance company pays me directly for services rendered by Laboratory, I am responsible for forwarding such payment to Laboratory.

Physician Oversight: I hereby authorize and direct clinicians for Rume Medical Group, (“Providers”), their subsidiaries, and affiliated physicians and medical staff to administer and interpret my results.

I understand that as a courtesy, Provider and/or its authorized agents will make every reasonable effort to obtain insurance reimbursement for consultations and visits. I understand that I am making an assignment of my insurance plan benefits to Provider and/or its authorized agents. I also authorize the release of any information contained in my records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with the same. Bill to my insurance: I understand that if my insurance company pays me directly for services rendered by Providers, I am responsible for forwarding such payment to Providers.