Assignment Of Benefits & Notice Of Privacy Policies Form

I irrevocably assign to, COLACURCIO WELLNESS LLC, all rights and benefits under any insurance contracts for payment for services rendered to me by Colacurcio Wellness LLC and it’s physicians, therapists, and independent contractors. This assignment specifically includes but is not limited to filing for personal injury protection benefits arbitration with the American Arbitration Association and/or filing a lawsuit to compel payment of personal injury benefits. I irrevocably authorize all information regarding my benefits under any insurance policy relating to any claims by Colacurcio Wellness LLC to be released to Colacurcio Wellness LLC. I also irrevocably authorize Colacurcio Wellness LLC to file insurance claims on my behalf for services rendered to me. I irrevocably authorize Colacurcio Wellness LLC to act in my behalf and report any suspected violations of proper claims practices to the proper regulatory authorities. I recognize that I am personally responsible for the payment of any medical services that are not paid by my insurance including any deductibles, co-insurance, and co-payments.

This assignment of benefits and notice of privacy policies has been explained to my full satisfaction, and I understand its nature and effect.

I acknowledge receipt of Colacurcio Wellness LLC. Notice of Privacy Practices, and I authorize Colacurcio Wellness LLC. and/or their billing service, if any, to discuss my medical and/or financial data with the following:

  • Name
  • Relationship
  • Phone Number

This notice also gives us permission to leave a message on your answering machine, send a scheduling related text, email, or message through social media.

Massage Therapy Late Cancellation Policy:

There will be a discretionary $35 fee on 60 minutes, $45 fee on 75 minutes, and a $55 fee on 90 minute massages if you “No Show” a previously scheduled massage therapy session or cancel within 4 hours up until the time of your massage appointment at Colacurcio Wellness LLC / Allure Day Spa & Salon LLC, Evolution Health & Fitness LLC. Our independent contractor massage therapists are still paid if a client doesn’t show up or doesn’t cancel within four hours prior to the scheduled appointment.

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Document name: Assignment Of Benefits & Notice Of Privacy Policies Form
lock iconUnique Document ID: ef4397d80f77f58c0ce65566050bc3354d34d7c5
Timestamp Audit
September 1, 2022 5:50 pm EDTAssignment Of Benefits & Notice Of Privacy Policies Form Uploaded by Steve Colacurcio - IP
December 7, 2023 1:41 pm EDT Document owner has handed over this document to 2023-12-07 13:41:42 -