By clicking "I agree" at the bottom of the form, I am agreeing to the disclaimer below.
I understand and consent that all of the information I am providing as part of this application will be used by Lineagen to determine whether I qualify for the Lineagen Care Program. I verify that the information on this application is complete, true, and accurate.
I understand that, if any of the information I have provided proves to be untrue, Lineagen may re-evaluate my financial status and take action as is necessary to collect an amount equal to the discount or waiver granted to me by Lineagen.
I also understand that if I am admitted to the Lineagen Care Program (LCP) there are terms and conditions with which I must comply to remain in the Plan. I hereby agree to: to remaining in the Lineagen Care Plan, if approved. I hereby agree to:
- Promptly forward to Lineagen any insurance payments I receive from my insurer for Lineagen genetic testing.
- Assist Lineagen in dealing with my insurer’s claims process by supplying Lineagen with the information that it needs to submit a claim to my insurer on my behalf.
- Assist Lineagen in pursuing all available appeals afforded by my insurer by providing Lineagen with all information and/or signatures needed for such appeals.
- Assist Lineagen with any other reasonable request that it makes to me for obtaining as much insurance coverage as is available from my health insurance plan for Lineagen’s testing services.
If I do not comply with these conditions, I understand that my participation in the LCP may be terminated, and, in the event of such termination, I will owe the remaining balance as it appears on my insurer’s Explanation of Benefits statement. Under certain circumstances outstanding patient balances will be referred to an outside collections agency.