I agree that I am responsible for paying for all products and services that I receive from Tandem, including deductibles, co-pays, or any other amount not covered by insurance. If provided with estimated out-of-pocket costs, I understand
that these are only estimates of my insurance benefits and are not a guarantee of coverage or the charges I am responsible for. I also understand that I am financially responsible for collection costs if my account becomes delinquent.
I hereby assign and transfer to Tandem all medical provider benefits payable under my insurance or benefit plans, including Medicare, Medicaid, Social Security, or other payors. I certify that the information I gave in applying for
payment under Medicare and Medicaid is correct, if applicable, and I authorize release of any information needed to act on this request. I authorize and direct the insurance company to pay all such benefits to Tandem and shall immediately
pay over these funds if they are made directly to me by insurance. I hereby assign and transfer all related rights and remedies due under the insurance or benefit plans that I have identified or will identify in connection with all
products and services rendered, including all rights and remedies pursuant to applicable state, federal, and ERISA regulation. By providing my email address or phone number to Tandem, I consent to Tandem and its agents or affiliates
communicating with me electronically regarding Tandem products and services and payment for such products and services. These communications may include text messages, auto-dialed calls, and/or pre-recorded calls. I understand that
electronic communications may not be secure and could be intercepted by others. I may opt out of electronic communications at any time by notifying Tandem. I acknowledge that a copy of the HIPAA Notice of Privacy Practices for Tandem
has been made available to me.
