This authorization permits Access to Coverage to communicate with health plans, insurance companies, managed care organizations, utilization review entities, and the patient's treating providers regarding insurance advocacy matters, including but not limited to Single Case Agreements (SCA), prior authorizations, coverage determinations, appeals, claims processing, reimbursement coordination, and related insurance matters.
The patient authorizes Access to Coverage to act as their Authorized Representative for purposes of communicating with insurance carriers, requesting and receiving information, submitting documentation, pursuing authorizations and appeals, and coordinating coverage and authorization matters on the patient's behalf. This authorization includes permission for insurance representatives to verbally discuss protected health information with Access to Coverage in connection with these services.
Insurance representatives are authorized to verbally discuss protected health information with Access to Coverage and to accept communications and submissions from Access to Coverage acting on the patient's behalf.

I authorize the disclosure of the following protected healthinformation: Patient identification details (name, DOB, address) • Treatment records, billing records, and clinical documentation relevant to insurance advocacy services, excluding psychotherapy notes unless separately authorized by the patient. • Any other records necessary to process the SCA
Recipient of Information:
Access to Coverage
Contact Information:
Usher Parnes
Phone: 732-475-2111
Fax: 800-342-2313
Email: cs@accesstocoverage.com

This authorization permits communication and administrative representation only and does not assign insurance benefits, transfer payment rights, or authorize Access to Coverage to receive insurance reimbursements.

The patient authorizes insurance carriers to communicate directly with Access to Coverage regarding the matters described in this authorization. The patient authorizes insurance representatives to verbally discussprotected health information with Access to Coverage and to acceptcommunications, submissions, and follow-up actions from Access to Coverage acting as the patient's Authorized Representative Information disclosed under this authorization may be used by Access to Coverage for administrative processing, documentation preparation, insurance advocacy services, and coordination of coverage and reimbursement matters on behalf of the patient.

*Attach photo of your insurance card:

This authorization shall remain valid for two (2) years from the date signed or until completion of insurance advocacy services, whichever occurs later, unless revoked earlier in writing.

I understand that:

1. I may revoke this authorization at any time by providing written notice to Access to Coverage, except to the extent that action has already been taken based on this authorization.
2. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.
3. My treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this authorization.

This authorization may be revoked at any time by submitting written notice via email or mail to Access to Coverage, except to the extent action has already been taken based on this authorization.

The patient authorizes Access to Coverage to submit prior authorization requests, appeals, supporting documentation, and coverage inquiries on the patient's behalf.

The patient authorizes communication via telephone, email, electronic transmission, and fax for purposes related to insurance advocacy and coverage coordination services.

THIS CONSULTING AGREEMENT (the "Agreement") dated this

BETWEEN Access to Coverage of 2 Grant Ave, Lakewood NJ 08701 (the "Contractor").AND

A. The Client is of the opinion that the Contractor has the necessar qualifications, experience, and abilities to provide services to the Client. B. The Contractor is agreeable to providing such services to the Client on the terms and conditions set out in this Agreement.

The matters described above and of the mutual benefits and obligations set forth in this Agreement, the receipt and sufficiency of which consideration is hereby acknowledged, the Client and the Contractor (individually the "Party" and collectively the "Parties" to this Agreement) agree as follows:

Access to Coverage provides administrative advocacy and coordination services only.

Contractor provides administrative advocacy services only and does not guarantee insurance approval, authorization, reimbursement, or payment. All determinations are made solely by the insurance carrier or plan administrator.

Application & Intake Fee - $150 (Non-Refundable)
This fee covers administrative intake, case review, document preparation, and initiation of advocacy services. The fee is earned upon engagement and is non-refundable regardless of outcome.

Advocacy Completion Fee - $1,000
If the insurance carrier authorizes coverage, grants a network exception, or otherwise allows reimbursement consideration following Contractor's advocacy efforts, a completion fee becomes due.
This fee compensates Contractor for administrative coordination, insurer communications, documentation preparation, and implementation support.

Payment is for services rendered and not for a guaranteed outcome.

Benefit Confirmation" or "Approval" means confirmation by the insurance carrier of authorization or eligibility for in-network reimbursement consideration and does not guarantee claim payment or reimbursement amounts.

The Client acknowledges that by signing this Agreement, they consent to all fees and charges as outlined. Any attempt to initiate a chargeback will require the Client to provide documentation supporting the dispute. The Contractor reserves the right to pursue legal remedies if a chargeback is initiated without valid grounds.
Zelle: Transfer to: cs@accesstocoverage.com
Check: Payable to: Access to Coverage Mail to: 2 Grant Ave, Lakewood NJ 08701 Or send a photo of the front and back of the check to: cs@accesstocoverage.com
Bank Transfer: Chase Bank - Email cs@accesstocoverage.com for transfer information.

Contractor is not a healthcare provider and does not provide medical, clinical, psychotherapy, or legal services. Contractor does not submit claims under its own National Provider Identifier (NPI).

The Parties intend compliance with all applicable federal and state healthcare laws, including Medicare and Medicaid regulations and the Federal Anti-Kickback Statute. Fees compensate Contractor solely for administrative services and are not intended to induce referrals or influence coverage determinations.

Client agrees to provide accurate and complete information. Contractor is not responsible for insurance denials, delays, or adverse determinations resulting from insurer policies, provider billing practices, or inaccurate information supplied by Client or third parties.

Treating providers remain solely responsible for clinical services, billing accuracy, coding, and compliance with payer requirements. Contractor provides administrative assistance only.

Contractor does not receive insurance reimbursements and is not an assignee of insurance benefits. All insurance payments remain payable solely to the Client and/or treating provider.

732-475-2111 cs@accesstocoverage.com www.accesstocoverage.com

LIMITATION OF LIABILITY:
Contractor shall not be liable for insurance carrier decisions, claim denials, reimbursement amounts, or processing delays. Contractor's total liability under this Agreement shall not exceed the total fees paid under this Agreement.

CAPACITY/INDEPENDENT CONTRACTOR: In providing the Services under this Agreement, it is expressly agreed that the Contractor is acting as an independent contractor and not as an employee. The Contractor and the Client acknowledge that this Agreement does not create a partnership or joint venture between them and is exclusively a contract for service

ENTIRE AGREEMENT: It is agreed that there is no representation, warranty, collateral agreement, or condition affecting this Agreement except as expressly provided in this Agreement.

AI / TECHNOLOGY DISCLOSURE:
Contractor may utilize secure technology platforms and automated systems, including artificial-intelligence-assisted tools, to support administrative processing while maintaining confidentiality safeguards.

GOVERNING LAW:
Contractor may utilize secure technology platforms and automated systems, including artificial-intelligence-assisted tools, to support administrative processing while maintaining confidentiality safeguards.

IN WITNESS WHEREOF, the Parties have duly affixed their signatures under hand and seal on this