Insurance Authorization and Assignment of Benefits and Release of Information

Insurance and Payment Authorization:

Juniper® programs are offered as a covered benefit by some health insurance plans. By listing the health plan name, group ID, and member ID, Juniper will be able to verify whether the participant is an eligible member with this covered benefit.

Payment Responsibility. I agree to pay for all services furnished to me by Innovations for Aging, LLC d/b/a Trellis and the Juniper® programs (collectively, “Juniper”) that are not paid in full by my insurance, government program benefits or other third-party payors, upon receipt of a statement, except as prohibited by Juniper’s contract with my health plan or applicable law.

Payment Authorization. I authorize Juniper to directly bill my health plan or third-party payor for services rendered to me by or on behalf of Juniper but acknowledge that Juniper is not obligated to submit claims to third-party payors on my behalf unless required by law or by its contract with a particular third party payor. I also authorize any third-party payor through which I may have benefits to make payment directly to Juniper for such services. I understand I am financially responsible to Juniper for charges not covered by my insurance, government program benefits or other third-party payors.

Release of Information:

I also authorize Juniper to use my personal information (including health information) and/or records about me to the extent permitted by law and to disclose such information to: (i) health care or social service providers or other persons involved in my care; (ii) health plans, insurers, or other third party payors for the purpose of claims administration, benefit determinations, benefit development, or quality initiatives; and (iii) persons or organizations in connection with Juniper’s health care operations and business management. I understand that authorizing the disclosure of this health information is voluntary, and that I can refuse to sign this authorization.