I hereby authorize ACV Centers to examine and treat myself or my child and to perform such diagnostic tests and/or x-rays as may be necessary for the duration of treatment for this injury or illness. I hereby authorize the release of any medical information necessary to process my Medicare and/or insurance claims and for any benefits payable under my policy be paid directly to Advanced Cardiac and Vascular Centers. I understand that this may include information related to the diagnosis and/or treatment of alcohol/substance abuse, psychological/mental health disorders, and/or HIV status. I understand that I am responsible for payment of any charges incurred. I accept this responsibility regardless of any reimbursement of coverage. In the case of Medicare, I am responsible for payment of any charges not paid by Medicare.
