RELEASE OF INFORMATION 

AND ASSIGNMENT OF BENEFITS

FINANCIAL RESPONSIBILITY/ASSIGNMENT OF BENEFITS

For those health care providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to direct to that provider any benefits of any policies of insurance to those health care providers who have rendered services to me and who accept such assignment.  I agree to pay all charges that are not paid in full under any policies of insurance.  If such amounts due to health care providers are not paid after reasonable notice, that account shall be deemed delinquent, and a service charge shall be added to the amount due.  If I default on payment of an account, I agree to be responsible for collection fees and interest due on amounts in default, including court costs and reasonable attorney’s fees.  If the debt is assigned to a third party for collection, I agree to be responsible for collections fees and interest due on amounts in default. 

RELEASE OF INFORMATION 

The health care provider involved in my care may release information about me necessary to substantiate insurance claims. 

MEDICARE LIFETIME BENEFICIARY CLAIM AUTHORIZATION AND RELEASE OF INFORMATION

I request that payment of authorized medical benefits be made either to me or on my behalf to Advanced Cardiac and Vascular Centers for any services furnished to me by the physician/supplier.  I authorize any holder of medical information about me to release to Centers for Medicare and Medicaid Services and its agents any information needed to determine benefits or the benefits payable for related services.

I understand my signature requests that payment be made, and I authorize release of medical information necessary to pay the claim.  If other health insurance is indicated on Item 9 of the HCFA-1500 claim form or elsewhere on the approved claim form or cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services.  Co-insurance and deductible are based upon the charge determination of the Medicare carrier.