Signature Required

IN ORDER TO COMPLETE THE INSURANCE SUBMISSION PROCESS, PLEASE REVIEW THE FOLLOWING AND SIGN WHERE INDICATED

Authorization for Payment and Assignment of Benefits

I request that payment of authorized Medicare, Medical Assistance, or other insurance benefits be made on my behalf to the ambulance company named on the front of my invoice. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to provider and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by provider, now or in the future, when applicable. I agree to immediately remit to provider any payments that I receive directly from any source for the services provided to me and I assign all rights to such payments to provider. Additionally, I authorize provider to perform all necessary and appropriate insurance claim appeals when my insurance carrier inappropriately processes my claim(s). I permit a copy of this authorization to be used in lieu of the original, where applicable. My signature certifies that I received a service or item on the date of service listed on the front of my invoice. I understand that payment for this service or item may be from Federal and State Funds and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State laws. The paragraph below DOES NOT apply to Medical Assistance Recipients.

I furthermore understand and agree to be financially responsible to provider for all charges not covered under my insurance subject to the protections afforded to me by my membership agreement or all State and/or Federal reimbursement programs and regulations. I agree that if payment is not made by my insurance company or applicable third party payer, I will be responsible for payment to provider. I understand that an additional collection fee may be applied to the account balance if submitted to a collection agency.

I have read and understand the above terms. I understand that typing my name in the signature box below represents my electronic signature of authorization for payment and assignment of benefits.

* Required Fields

Signature of Patient or Authorized Representative *
(please type your name here)

Date *


MM	DD	YYYY

* If patient is unable to sign, an authorized representative may sign on behalf of patient. Signature by an authorized representative authorizes release of medical information as needed for treatment, payment, and operations, and authorization to bill Medicare, Medicaid, and/or any other insurance carrier on behalf of the patient. The signature DOES NOT obligate the representative to pay for services.

Relationship to patient

Reason patient is unable to sign


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* To ensure security, please check the box below next to the phrase "I'm not a robot" to verify that you are an actual human submitting this information.