NOTICE OF PRIVACY PRACTICES

AUTHORIZATION OF BENEFITS

Statement to Permit Payment Of Medicare Benefits to Provider
“I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical information about me to release to the Health Care Financing Administration or its intermediary any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for covered Medicare services to Roadrunner Mobility as provider furnishing services.”

Lifetime Beneficiary Authorization For Period of Confinement
“I request that payment under any medical insurance program be made to Roadrunner Mobility on any bills for services furnished by Roadrunner Mobility.”

Agreement To Pay
As Roadrunner Mobility has agreed to supply patient with any supplies and services ordered by patient or on behalf of patient, the undersigned patient or responsible party agrees that each of them is responsible for payment for all such supplies and services provided to patient.

Assignment Of Benefits
The undersigned hereby authorize Roadrunner Mobility to request on my/our behalf and to collect directly all public and private insurance coverage benefits due for supplies and services supplied by Roadrunner Mobility. In the event payments for insurance benefits are made directly to any of the undersigned, the payee will endorse to Roadrunner Mobility all checks for such payments.

Release Of Information
The undersigned hereby authorize our insurer(s) and any other third party payor who provides patient with coverage to disclose to Roadrunner Mobility any information regarding such coverage, including but not limited to 1) payments made by such insurer(s) or third party payor(s) to any of us, for supplies and services rendered to patient by Roadrunner Mobility and 2) the scope and extent of coverage available from time to time. Patient authorizes all medical personnel to provide information to Roadrunner Mobility concerning patient/client medical history, as it may relate to patient/client supplies and services. The undersigned consents to the review of patient/client records including medical records by any Federal, State, or Accrediting Body or Agency as required by the Regulatory, Licensing, or Accrediting Body.

Notice of Use

Privacy Policy
Roadrunner Mobility cares about protecting its customers’ privacy. In the process of providing the products and services you requested, we will collect, use and share certain information you provided. This Privacy Policy explains what information we collect and how we use that information. The policy also explains how we protect the security and confidentiality of your information.

Collection of Information
We collect and retain the information necessary for us to provide the products and services you requested. In that process we may collect non-public information from you as a result of your request for supplies and services from Roadrunner Mobility.

Sharing Information
We may share information with certain non-affiliated companies or individuals, including providers inquiring about benefits, family or legal representatives acting on your behalf, and to comply with legal or regulatory requirements.

Internal Protection of Information
We restrict access to non-public personal information about you to those employees who need to know that information to provide the products and services you requested. We maintain physical, electronic and procedural safeguards to comply with federal regulations to guard this information.

Disclosure of Our Privacy Policy
We are sending you this Notice for informational purposes and may amend this policy at any time and will update it as required.