Medical Release
I
hereby authorize release of medical
information pertaining to me and/or
my family to any licensed physician,
medical practitioner, hospital,
clinic or other medical related
facility, the Medical Information
Bureau or other organization,
institution, or its designated
agents. This authorization is
effective when I click the submit
button below and remains in effect
as long as I am a member of ABA.
I understand that I am entitled
to a copy of this authorization
if I request it. I understand
that the benefits offered through
membership in ABA are primarily
discounts from health care providers
and pharmacies that are contracted
with ABA or affiliate organizations.
Neither ABA nor its affiliated
organizations are insurers or
providers of medical services.
The services they render members
are referrals to physicians, specialists,
hospitals, other medical service
facilities, or pharmacies who
will provide medical services
or prescription drugs, file the
necessary claim forms with ABA,
and give the member a discount
from their usual charges. I understand
that I am responsible for paying
the discounted cost of services
and associated fees as invoiced
by ABA within 20 days of receipt
of such invoices. I am hereby
informed that failure to pay within
the allotted tome without making
alternative payment arrangements
will cause forfeiture of all discounts
and termination of membership.
I further understand that I am
liable for any deliberate unauthorized
use of my membership card, that
such use constitutes theft of
services and could cause irreparable
harm to ABA's ability to maintain
provider contracts.
Check-O-Matic Authorization
I
authorize American Benefits Association
or its designated agent to electronically
draft my account for my annual
membership fee. The name of my
bank is listed above for my monthly
membership fee. I instruct my
bank, as identified below, to
honor checks drawn in the name
of American Benefits Association
or its designated agent acting
as the Association's agent-in-fact
as a convenience to me to charge
my account and to pay the Association's
account the amount stated in the
electronic transfer. This authorization
is to remain in effect until revoked
by me in writing and you, my bank,
shall be fully protected in honoring
any such check or electronic debit.
I agree that if your treatment
of each check or electronic debit
is dishonored, whether with or
without cause, the bank shall
be under no liability. I have
agreed to have American Benefits
Association or its designated
agent safeguard this authorization,
along with my voided check, to
you, the bank I have named below.
I understand that if for any reason
a scheduled transfer is rejected
by my bank an additional $5.00
charge will apply.
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