Insurance Eligibility and Benefit Request

Matia Mobility is helping to streamline the process of securing insurance coverage, making it easier, faster, and more efficient for you to get the approvals you need. Please fill out the form below as completely as possible and one of our insurance experts will be in touch with you.

Matia Mobility Eligibility and Benefit Request

PreAuthForm

State Where Patient Resides

State

Provider Information

Physician Name

Name of Practice

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Clinical Contact Name

Contact Email

Office Phone

Office Fax

Patient Information

Patient Name

Phone

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Information

Type of Coverage

Medicare

Medicaid

Commercial

Worker’s Comp

Claim #

Date of Injury

Primary Insurance

Policy Number

Insurance Company Provider Phone Number

Fax Number

Group Number

Subscriber Name

Upload Insurance Card (front and back)

Choose File

Secondary Insurance

Do you have Secondary Insurance?

Yes

Secondary Insurance

Policy Number

Phone/Mobile

Fax Number

Group Number

PTAN Number

Subscriber Name

Upload Insurance Card (front and back)

Choose File

Assignment of Benefits (AOB)

1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Matia Robotics US Inc D/B/A Matia Mobility (Matia Mobility) and/or any of our corporate affiliates for medical supplies and/or medication(s) furnished to me by Matia Mobility.

2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s).

3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents and assigns.

4. Matia Mobility and/or any of our corporate affiliates to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided.

5. Matia Mobility and/or any of our corporate affiliates to contact me by telephone or mail regarding my medical supplies and/or medication(s) order.

I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible.

I request that payment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to Matia Mobility and/or any of our corporate affiliates for any medical supplies and/or medications furnished to me by Matia Mobility. I authorize any holder of medical information about me to release to Matia Mobility, my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurer any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurer(s) and for which I am responsible.

I have read and agree to the Assignment of Benefits (AOB) above

Signature

Sign Here

Disclaimer: Coverage and Authorization Services are provided for your convenience only and are not intended to be a recommendation regarding clinical practice, or any representation or warranty regarding payment or as a guarantee of payment by any payer. It is the responsibility of the provider to ensure that appropriate claims and charges for services that were rendered are submitted. Matia Mobility is not and shall not be liable for the cost of the patient’s medical treatment under any circumstance. Matia Mobility provides assistance on prior authorization requests for FDA approved or cleared indications. Where reimbursement is requested for a use of a product that may be inconsistent or not expressly specified in the FDA cleared or approved labeling (e.g., Instructions for use, operator’s manual or package insert) consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related services. Contact your Medicare contractor or other payer for interpretation of coverage, coding, and payment policies.