Exhibit D: Provider and Group Authorization to Represent

This Provider and Group Authorization to Represent (“Authorization”) is executed by [Client.Company] (“Customer”) and grants pie Health, LLC (“Supplier”) the authority to act on Customer’s behalf, including any associated providers, facilities, or locations designated in writing or through credentialing documentation, for the purposes of performing Services under the General Services Agreement (“Agreement”) between the parties.

​This Authorization is effective as of the effective date of the Agreement and shall remain in effect for the duration of the Agreement and any related Statement(s) of Work.

• Commercial and government insurance payors

• Clearinghouses, billing vendors, and RCM companies

• Previous or current credentialing service providers

This authorization includes, but is not limited to:

• Requesting enrollment status or credentialing records

• Investigating claim holds, denials, or delays

• Confirming billing setup and linking NPI/Tax ID data to payor records

• Receiving verbal or written responses on behalf of the Customer

This authorization does not permit pie to sign contracts, agree to participation terms, or make financial or legal commitments on behalf of the Customer unless separately authorized in writing.

This authorization is valid for the duration of the Services under the General Services Agreement and any related Statement(s) of Work, unless revoked in writing.

CUSTOMER
Signature Printed Name: (Clients Authorized Signer) Date: