1. Appointment of Representative
By signing below, I appoint Medical Bill as my Authorized Representative for the purpose of reviewing my medical bills and insurance claims and preparing, submitting, and tracking disputes, appeals, grievances, reconsiderations, corrected claims requests, and related complaints or inquiries with my health plan/insurer, health care providers, and applicable regulators.
2. Scope of Authority
This appointment authorizes Medical Bill to:
2.1 Communication with Insurers & Providers
Communicate with my health plan/insurer, providers, and their administrators about my account, claims, and coverage, including sharing and receiving information needed to resolve my bill or appeal.
2.2 Records & Document Access
Request, receive, and exchange claim files, EOBs, itemized bills, medical records relevant to the claim, prior-auth/referral info, coding notes, and plan documents (EOC/SBC/benefit booklets).
2.3 Appeal & Dispute Submission
Prepare, sign (on my behalf where permitted), and submit plan appeal/grievance forms, cover letters, corrected-claim requests, and supporting documentation; respond to Requests for Information (RFIs); and select the submission channel (fax, mail, email, secure upload, or regulator portals).
2.4 Regulatory Complaints
File consumer complaints or inquiries with applicable oversight agencies (e.g., state DOI, DOL/EBSA for ERISA, HHS/OCR for Right-of-Access issues) when necessary to obtain records or enforce timelines — not to seek legal remedies.
2.5 Receiving Correspondence
Receive copies of decisions, acknowledgments, and correspondence about my case.
2.6 Use of Service Providers
Use vetted service providers (e.g., e-fax, print-and-mail, virtual mailbox, document storage) to perform these tasks.
3. Limitations
Medical Bill is not a law firm and does not provide legal or medical advice or represent me in hearings.
Medical Bill will not accept or hold refunds or benefits on my behalf; any payments or adjustments must be issued directly to me or my provider.
4. Duration & Revocation
This Authorized Representative Form (AOR) is effective on the date I sign and remains in effect until revoked.
I may revoke this authorization at any time by emailing support@medicalbill.pro. My revocation will not affect actions already taken under this authorization prior to the date of revocation.
5. Acknowledgment
I certify that the information I provide is true and accurate, and that I have the authority to sign for the person named below (if not myself).
By signing electronically in the Medical Bill application, I acknowledge that I have read and understood this Authorized Representative Form and voluntarily appoint Medical Bill as my authorized representative under the terms described above.
6. Contact Us
If you have any questions about this Authorized Representative Form, please contact us at:
Email: support@medicalbill.pro