I hereby authorize INSNET and its representatives, agents, subsidiaries and affiliates (collectively, "INSNET") to utilize any personal demographic, personal financial and personal health care information that I have provided to INSNET, including without limitation through the INSNET web site or toll-free business line, for the purpose of attempting to obtain a reduction in health care claim liability on behalf of me or one of my family members.
I authorize INSNET and its employees to act as my/the patient’s authorized representative for the solitary purpose of obtaining such reductions in health care claim liability, and to disclose or utilize such information only in discussions with my health care provider for such purpose.
I authorize my/the patient’s health care provider to release and/or discuss my/the patient’s personal health care information to and with INSNET for the purpose of attempting to obtain a reduction in health care claim liability on behalf of me or one of my family Such personal health care information may include billing and procedure information and any medical records describing the health care services provided to me by my/the patient’s health care I also authorize the release of personal health care information related to HIV, AIDS, drug and alcohol treatment, diagnosis and/or mental health and/or developmental disability treatment or other diagnostic information included in the information provided to INSNET by me and authorize that such information be disclosed and utilized by INSNET, as well as the associated health care providers, for the purpose of obtaining a reduction in health care claim I understand that if I authorize the release of drug and alcohol treatment information, such information cannot be re-disclosed by a recipient without my specific consent.
I authorize the transmission of personal demographic, personal financial and personal health care information, in accordance with INSNET operating policies, including without limitation via e-mail, fax, or other means of electronic transmission, and hold INSNET harmless from any and all claims that might arise from the risks associated with accidental disclosure of personal information, which is inherent in an electronic transmission.
I understand that this authorization, in its entirety, may be revoked in writing at any time except to the extent that any actions have been taken in reliance I also understand that the information released may be subject to re-disclosure unless otherwise protected by This authorization is valid for the period of time necessary to conduct a review of the health care charges and negotiate a settlement with the provider of health care services, and shall expire when either a full and accurate financial transaction has been concluded with the provider of health care services, or INSNET finalizes its process without obtaining a reduction in health care expenses.
I acknowledge that I am 18 years old or older, that I have read the explanation of services provided on the INSNET web site, that I have provided INSNET with information about the health care bill that has been submitted to me by my/the patient’s health care provider along with my credit or debit card information, allowing INSNET to utilize this information for the sole purpose of negotiating with my health care provider for a reduction in my health care claim If I am the responsible party but not the patient referenced in the health care bill submitted to INSNET, I have authority to act on behalf of the patient, and if the patient is a minor, I am the parent and/or legal guardian of the minor and I enter into this agreement, release and authorization on behalf of the minor identified in the health care bill.
I hereby authorize INSNET to negotiate with my/the patient’s health care provider regarding each and every health care bill that I submit to INSNET and I expressly authorize INSNET to agree on my behalf that I will pay to that health care provider any amount agreed upon between INSNET and that health care provider that will result in at least a 5% (five percent) reduction of the original health care claim liability amount (the Minimum Reduction I understand the INSNET is to be paid a fee equal to the applicable percentage of the savings, [such applicable percentage amount as specified at the time that I accessed the INSNET web site,] and that INSNET will attempt to save me more money when possible.
In signing up for this service, I have provided to INSNET my credit or debit card information, and I agree that INSNET will pre-authorize my credit or debit card to assure that I have sufficient credit or funds to to pay the INSNET fee. I understand there is no fee if INSNET does not save me money on my bill. I also understand INSNET is not paying this bill on my behalf. I will receive a Transaction Summary from INSNET with detailed payment instructions which will include a contact name and telephone person at the medical provider. It will be my responsibility to contact this person and provide them with my credit / debit card information for the purposes of paying my medical liablility.
If INSNET is able to reach an agreement with my/the patient’s health care provider for a reduction that meets or exceeds the Minimum Reduction Amount, I expressly authorize INSNET to provide to the health care provider my credit or debit card information (including specifically the cardholder’s name, address, telephone number and/or e-mail address and the card type, number, security code and expiration date) for the express purpose of allowing the health care provider to charge the card in satisfaction of the health care claim liability, up to and including 95% (ninety-five percent) of the original amount of the health care claim liability at I understand that it remains my obligation to pay the health care bills from my/the patient’s health care provider and that INSNET, by agreeing to negotiate on my behalf, has not agreed to accept any liability or responsibility for making those payments.
If INSNET is able to reach an agreement with my/the patient’s health care provider for a reduction in my health care claim liability that meets or exceeds the Minimum Reduction Amount, I further agree that INSNET is entitled to a fee equal to a certain percentage, as specified on the INSNET web site, of the savings to me and I expressly authorize INSNET to charge my credit or debit card for that Further, I agree that INSNET is entitled to this fee once an agreement is reached even if I later dispute the health care provider’s charges for any reason, and I will not be entitled to a refund. If INSNET cannot reach an agreement that meets or exceeds the Minimum Reduction Amount, I understand that I will not be charged any fee for INSNET’s services.
With a full understanding of this proposed transaction, I hereby release INSNET and its officers, directors, members, agents and employees from any and all claims relating to the contemplated transaction, including any claims that I may have for alleged violation of my privacy rights under state or federal law relating to health care records and information, any claims that I may have relating to the use or proposed use of my credit or debit card and billing information, and any and all other claims arising out of or relating to the transactions authorized by me; and I further agree to indemnify and hold harmless INSNET from any and all claims asserted by me or any third party, including but not limited to my health care provider(s), arising out of or relating to the transactions authorized by me upon acceptance of this Consumer Agreement and Release, or arising out of or relating to any breach of a representation made by me herein, such indemnification to be enforceable to the maximum extent permitted by applicable law.
I certify that I have read the foregoing, and either I am the financially responsible party or I am duly authorized by the patient’s general agent to execute the above and accept these terms.
I have read the foregoing Consumer Agreement and Release and accept the terms and conditions set forth above.
Signature of Patient or Patient Representative Date
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