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Physicians & Nurses Signup Form

Please use the form below to set up your account at TealHeal. Once this form is submitted, our team will contact you to assist you with next steps.

Email address

A valid email address. All emails from the system will be sent to this address. The email address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by email.

Username

Several special characters are allowed, including space, period (.), hyphen (-), apostrophe ('), underscore (_), and the @ sign.

Password

Confirm password

Provide a password for the new account in both fields.

Assignment of benefits

ASSIGNMENT OF BENEFITS AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

Patient Consent: I agree the specimen identified on this form is my own and it is not altered. I am voluntarily submitting this specimen for the purpose to enhance patient care, providing objective documentation of my treatment plan for my physician. I hereby authorize my physician to release personal health information to Neoanalytics Laboratory for any purposes, consistent with HIPAA including billing, audits and other purposes.

I UNDERSTAND AND AGREE THAT: This authorization is voluntary. My health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information: I may not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits if I do not sign this form my health information may be subject to re-disclosure by the recipient, and of the recipient is not a health plan or health care provider. The information may no longer be protected by federal privacy regulation, This authorization will expire one year from the date I sign the authorization. I may revoke this authorization at any time by notifying my insurance policy in writing. However, the revocation will not have an effect on any actions taken prior to the date of my revocation is received and processed.

ASSIGNMENT OF BENEFITS: I hereby authorized and want the payment to go to Neoanalytics Laboratory to receive payment for this bill from my insurance company (THIS IS AN “ ASSIGNMENT”). I want my health insurer to pay the provider for any health care services I or my dependent received that are covered under my health insurance. With my assignment, the provider cannot seek payment from me except for any copayment, coinsurance or deductible that would be owed. If my insurer paid me for the services, I agree to send the payment to the provider within 15 days with a tracking number.

APPEAL AUTHORIZATION: I hereby authorize Neoanalytics Laboratory Inc and their designee to act as my financial representative in requesting: A complaint, An appeal, and documents from my insurance provider regarding the services provided. This authorization will expire in one year from the date of my revocation is received and processed. I understand that if any insurer doesn’t pay or denies the claim as a uncovered service, I am responsible. If my insurer pays me directly, I agree to endorse the check and forward it to Neoanalytics Laboratory within 15 days.

I,do hereby allowed Neoanalytics Laboratory or a CLIA CERTIFIED Laboratory to act as my financial representative in requesting a complaint, an appeal and documents from my insurance provider regarding the services provided. I authorization for assignment of benefits, the undersigned authorize my insurance to make payment for benefits due herein to:

PROVIDER: NEOANALYTICS LABORATORY INC
PROVIDER ADDRESS: 25 S RAYMOND AVENUE SUITE 204, ALHAMBRA CA 91801
CLIA #: 05D2153457      TAX ID: 82-5396237

Physicians & Nurses Signup Form

Date of Birth