Charges & Financial Obligations · Permission or license
The signer assigns Medicare benefits and payment rights for the Services to Practice
The signer confirms they requested Services from Practice and assigns to Practice all applicable health insurance benefits and payments (each a “Benefit”) and all rights to which they are entitled, or which they have actually received, from Medicare in connection with the Services. The signer also certifies that the information they gave when applying for Medicare is correct.
Supporting quotations
I hereby assign to Practice all applicable health insurance benefits and payments (each such payment or benefit, a “Benefit”) and all rights to which I am entitled (or which I have actually received) from Medicare in connection with the Services
I certify that the information I provided in applying for Medicare is correct
Qualifications & exceptions
The assignment is “in connection with the Services.”
A “Benefit” is each such payment or benefit.
Not stated here
Whether “from Medicare” limits both the benefits and the rights, or only the rights, is not clear from the wording.
Charges & Financial Obligations · Permission or license
The signer directs Medicare to pay Practice directly
The signer directs Medicare and its contractors to issue payment checks directly to Practice.
Supporting quotations
I direct Medicare and its contractors to issue payment checks directly to Practice.
Qualifications & exceptions
The direction is addressed to Medicare and its contractors.
Charges & Financial Obligations · Procedure
The signer must forward Medicare checks and EOBs to Practice within 30 days or may owe the total charge
If the signer receives direct payment of amounts due for the Services along with an Explanation of Benefits (EOB), they agree to forward promptly to Practice any check made out to them, endorsed to Practice, and any related EOB. Steps listed: notify Practice on receipt, endorse the check “Pay to the Order of WHOOP Physician Services, P.C.”, mail the check and EOB right away, and keep copies. If the signer does not forward the check and EOB within thirty days of receipt, they may be held responsible for the total charge for the Services. Elsewhere the Consent says the Services are provided to the signer free of charge, and this text does not explain how the two fit together.
Supporting quotations
In the event that I receive direct payment of any amounts due for Services rendered by Practice and an Explanation of Benefits (“EOB”) related to such Services, I agree to forward promptly to Practice any checks made payable to me for Services rendered, endorsed to the order of Practice, and any related EOB
(ii) endorse the check “Pay to the Order of WHOOP Physician Services, P.C.”
in the event I fail to forward the check and EOB to Practice within thirty (30) days of receipt, I may be held responsible for the total charge for the Services
the Services will be provided to me free of charge, and that any deductibles, co-payments, or co-insurance related to the Services will be waived by Practice in accordance with the terms of the ACCESS Program and 42 C.F.R. § 1001.952(ii)(2)
Qualifications & exceptions
The duty arises only if the signer receives direct payment and an EOB.
The consequence is that the signer “may be held responsible”; it is not stated as automatic.
The 30-day period runs from receipt.
The Consent separately says the Services are provided free of charge.
Not stated here
“Total charge” is not defined or quantified in this text.
How the total-charge consequence fits with the free-of-charge statement is not explained.
Cross-references
contrast (model-proposed): The Services are free to the signer and cost-sharing is waived — contrast: One paragraph says the Services are free of charge with cost-sharing waived; another says a signer who does not forward a Medicare check and EOB within thirty days may be held responsible for the total charge for the Services. The text does not explain how the two fit together.
Charges & Financial Obligations · Company commitment
The Services are free to the signer and cost-sharing is waived
The signer acknowledges that the Services will be provided to them free of charge and that any deductibles, co-payments or co-insurance related to the Services will be waived by Practice in accordance with the terms of the ACCESS Program and 42 C.F.R. § 1001.952(ii)(2). This sits under the heading “Financial Responsibility.” The Consent also says the signer may be held responsible for the total charge if they do not forward Medicare checks and EOBs within thirty days, and that the signer remains responsible for fees for WHOOP, Inc. offerings.
Supporting quotations
the Services will be provided to me free of charge, and that any deductibles, co-payments, or co-insurance related to the Services will be waived by Practice in accordance with the terms of the ACCESS Program and 42 C.F.R. § 1001.952(ii)(2)
Financial Responsibility
in the event I fail to forward the check and EOB to Practice within thirty (30) days of receipt, I may be held responsible for the total charge for the Services
Qualifications & exceptions
The waiver is “in accordance with the terms of the ACCESS Program and 42 C.F.R. § 1001.952(ii)(2).”
The next paragraph carves out fees for WHOOP, Inc. services, products and features.
The check-forwarding clause says the signer may be held responsible for the total charge if checks and EOBs are not forwarded within thirty days.
Not stated here
The ACCESS Program terms and the cited regulation are not supplied in this document, so the exact limits of the waiver are not analyzed here.
How the free-of-charge statement fits with the total-charge consequence is not explained.
Charges & Financial Obligations · Restriction or exception
The signer remains responsible for fees for WHOOP, Inc. offerings and Band upgrades
Despite the free-of-charge statement, the signer agrees to be responsible for any fees or charges related to any services, products or features offered by WHOOP, Inc., including WHOOP Advanced Labs, Clinician in the Loop and any upgrades to the WHOOP Band.
Supporting quotations
Notwithstanding the foregoing, I acknowledge and agree that I will be responsible for any fees or charges related to any services, products, or features offered by WHOOP, Inc., including WHOOP Advanced Labs, Clinician in the Loop, and any upgrades to the WHOOP Band
Qualifications & exceptions
Opens with “Notwithstanding the foregoing,” which carves it out of the free-of-charge paragraph.
Covers offerings of WHOOP, Inc.; the examples are introduced by “including,” so the list is not limited to them.
Not stated here
Prices and terms for these offerings are not in this text.
Which WHOOP terms govern those offerings is not stated here.