b'Assignment and Designation of Authorized Representative BIOPLUS SPECIALTY PHARMACY PATIENT GUIDEBOOKIf you are a Medicare patient, BioPlus Specialty Pharmacy, a Carelon company, is not permitted to submit a claim to Medicare without this form signed by you. If we do not receive this form within seven days of you receiving this wel-come kit, you may be required to pay for your medications. Considering the amount of medical expenses to be incurred, I, the undersigned, state that I have health insurance and/or employee healthcare benefits that will pay for the healthcare to be provided by BioPlus Specialty Pharmacy and their network of pharmacies: MedScripts Medical Pharmacy, River Medical Pharmacy, Route 300 Pharmacy, and Santa Barbara Specialty Pharmacy (each Pharmacy). I give the pharmacy all the rights I have for healthcare to be paid for through insurance and/or though my employee healthcare benefit plan (self-insured or fully-insured). This document is a designation of authorized representation and an assignment to the pharmacy of my right to health insurance and/or healthcare benefits (self-insured or fully-insured). The details of this authorized representation and assignment are set forth below.I hereby assign and convey directly to the pharmacy, as my assignee and designated authorized representative, allmedical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, devices, and/or medications rendered or provided by the pharmacy, regardless of its managed care network partici-pation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the pharmacy to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named healthcare provider any and all employee benefit plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named healthcare provider or its attorneys in order to claim such medical benefits.In addition to the assignment of the medical benefits and/or insurance and/or plan reimbursement above, I also assign and/or convey to the pharmacy any legal, equitable, or administrative claim, or chose inaction arising under any group health plan, employee benefits plan (self-insured or fully insured), health insurance, or tort feasor insurance concern-ing medical expenses incurred as a result of the medical services, treatments, therapies, devices, and/or medications I receive from the pharmacy (including any right to pursue those legal, equitable, or administrative claims or chose inaction). This constitutes an express and knowing assignment of ERISA* breach or fiduciary duty claims and other legal and/or administrative claims.* ERISA is an acronym for a Federal law entitled the Employee Retirement Income Security Act. ERISA governs most group health benefits provided by employee benefit plans. A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their depen-dents directly or through insurance, reimbursement, or otherwise. Most private sector health plans are covered by ERISA. Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan in formation. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law.30 The BioPlus Family of Pharmacies'