ReActiv8 Support & Verification Program

Consent and Authorization: By providing my information and signing this form, I give MML US, Inc. and its employees, agents, and contractors involved in managing the RSVP Program (collectively, “Mainstay Medical”), consent to utilize my Protected Health Information (PHI) and pursue insurance coverage on my behalf for the ReActiv8 system. I understand Mainstay Medical will act as my authorized representative to prepare and submit a pre-service or pre authorization request (prior auth.), as applicable, to my insurance company. If the prior auth. request is denied and I wish to file an appeal, I also authorize Mainstay Medical to continue acting as my authorized representative in pursuing an appeal against my insurance company. For this purpose, Mainstay Medical may use any additional PHI received from me or my physician/provider, including clinical records and insurance information, and I agree to complete (and sign) any necessary documents. I understand that participating in the RSVP Program is voluntary, and I may refuse to participate (or stop participating) without negatively affecting my treatment, insurance benefits, or physician-patient relationship. I understand neither Mainstay Medical nor the RSVP Program can promise or guarantee insurance coverage.. In addition, I authorize the above-identified physician and his/her facility/practice (“Practice”) to share my PHI with Mainstay Medical for purposes of preparing and submitting prior auth. request(s), appeal(s), grievance(s) and/or independent review(s) on my behalf to my insurance company, for purposes of obtaining ReActiv8 coverage. The following PHI may be disclosed to Mainstay Medical: Medical Records: All records, reports, charts, tests, correspondence, and notes from physician office(s), hospital(s), laborator(ies), physical therapist(s) and/or other providers, that pertain to my medical care, treatment, history, and/or prognosis relevant to ReActiv8 therapy. Insurance Records: All communications, notes, billing statements, claim forms, EOBs, enrollment information, premium information, and other relevant data to/from insurance companies, plans, administrators, sponsors, and utilization review companies, regarding processing or paying my claim(s) for insurance benefits. I understand that (i) my agreement with the above terms is voluntary and my treatment, payment, enrollment, or benefits cannot be conditioned on my signing this form; (ii) my PHI is protected by HIPAA (45 CFR Parts 160 and 164) and applicable state privacy laws; (iii) my PHI may be subject to re-disclosure without federal protection if the receiving party is not a health plan, health care provider, or healthcare clearinghouse; (iv) I am authorizing the release or exchange of my PHI to the parties named above; and (v) I can receive a copy of this form by submitting a request to Mainstay Medical. This authorization will expire one (1) year from the date entered above OR upon conclusion of my appeal process, whichever is later. I understand I can revoke this authorization at any time by notifying Mainstay Medical; however, my revocation will not have any effect on actions taken prior to the revocation.