Authorization

Note that, by subscribing, you (the subscriber) authorize that payment of authorized Medicare benefits or other insurance benefits be made on your behalf for any services furnished by this health service provided or supplier. You authorize any holder of medical information or documentation about you to release to the Health Care Financing Administration and its carrier and agents, as well as this health service provider, any information or documentation needed to determine these benefits or benefits payable for any service provided to you by this health service provider now or in the future. You understand that you are financially responsible for the services provided to you or your family members by this health service provider or supplier regardless of your insurance coverage. You request that payment of authorized Medicare or other insurance benefits be made on your behalf to the health service provider or supplier or its billing agent for any services provided to you by the health provider or supplier. You authorize and direct any holder of medical information or documentation about you to release to the Center for Medicare and Medicaid Services and its carriers and agents, as well as to this health provider or supplier and their billing agents, any information or documentation needed to determine these benefits payable for any service provided to you by the health service provider, both now or in the future. A copy of this form is valid as the original. You also agree to immediately remit to this health service provider any payments that you receive directly from any source for the services provided to you, now or in the future.