Click here to read the Financial Policy. By checking the box below, you agree to the statements noted on the policy
AUTHORIZATION FOR SUBMISSION OF CLAIMS AND ASSIGNMENT OF BENEFITS
I authorize the health care provider named above to submit claims for payment for services to the healthcare service plans or insurance companies named below, on my behalf and in my name, and assign to such provider the group insurance benefits otherwise payable to me, but not to exceed the provider's actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.
NOTICE OF PRIVACY PRACTICES
Click here to read the Notice of Privacy Practices. By checking the box below, you acknowledge the receipt of Notice of Privacy Practices.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I authorize the physician, dentist or other health care provider named above to release to hospital or health care service plans, insurance companies, self-insurers, or their representatives, any and all information and records (including x-rays) about my medical history, or about services rendered or treatment given to me, that is needed to review, investigate or evaluate any claim for benefits.
If my coverage is under a group master agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall remain effective for up to five years from this Date.
I know that I have the right to receive a copy of this authorization if requested.