FILING INSURANCE CLAIMS IS A SERVICE PROVIDED TO ME WITHOUT CHARGE AND IN NO WAY RELIEVES ME OF MY RESPONSIBILITY FOR MY BILL.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I authorize the release of any and all medical information necessary and required by my insurance company. This release will remain in effect until revoked by me in writing. A photocopy of this release is to be considered as valid as the original.
ASSIGNMENT OF BENEFITS: I hereby assign, transfer, and set over to Charleston Anesthesia Group, L.L.C. all of my rights, title and interest to my medical reimbursement benefits under my insurance company. This assignment will remain in effect until revoked by me in writing. A photocopy of this release is considered to be as valid as an original. This Assignment of Benefits clause does apply to active duty military personnel. |