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

Part A: Authorization to release my health information

I authorize the release of my health information as described below (45 CFR 164.508).

Who may release my information. Any physician, nurse practitioner, physician assistant, therapist, clinic, hospital, health system, or other health care provider that has evaluated or treated me, and any records department or release-of-information vendor acting for them. This includes, but is not limited to the list below.

Who may receive my information. Matia Mobility, 1929 S 4130 W, Suite A, Salt Lake City, UT 84104. Fax: 801.997.1813. Email: insurance@matiamobility.com. Phone: 801.997.1812.

What information may be released. Records from the 24 months before the date I sign, and records created after I sign until this authorization expires:

• Office visit notes, progress notes, and history and physical exams
• Physical therapy and occupational therapy evaluations and notes, including seating and mobility evaluations
• Diagnoses, problem list, and medication list
• Imaging and diagnostic test reports
• Hospital and rehabilitation discharge summaries
• Orders, prescriptions, referrals, and letters of medical necessity for mobility equipment

This authorization does not include psychotherapy notes or substance use disorder treatment program records.

Purpose. To allow Matia Mobility to obtain insurance coverage, prior authorization, and payment for my mobility equipment, including claims, appeals, and related communication with my health plan.

Communication. My providers and their staff may speak with Matia Mobility about the records and documentation needed for my mobility equipment.

How to send. Electronic copies by secure email, fax, or provider portal where available. Paper copies otherwise.

Expiration. This authorization expires one year from the date I sign it.

Part B: Request for access to my own records

Under my right of access (45 CFR 164.524), I request a copy of the records described in Part A. I direct each provider to send that copy to Matia Mobility at the address, fax, or email listed in Part A.

• Format: an electronic copy (PDF) where my records are kept electronically.
• Timing: I understand the provider must act on this request within 30 days.
• Questions or fees: contact Matia Mobility at 801.997.1812 before charging any copying fee.

Your rights

• You can revoke this authorization. Send a written notice to Matia Mobility at the address in Part A, or to the provider holding your records. Revocation does not affect information already released before the notice was received.
• Signing is voluntary. Your treatment, payment, enrollment, and eligibility for benefits do not depend on whether you sign. If you choose not to sign, you can give your records to Matia Mobility yourself.
• Redisclosure. Information released under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law. Matia Mobility will use your records only for the purpose described in Part A.
• Your copy. You will receive a copy of this signed form.