I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by "Provider" now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by "Provider", regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to "Provider" any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to "Provider" I authorize "Provider" to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or other relevant documentation about me to release such information to "Provider" and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payors or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by "Provider", now, in the past, or in the future.
I acknowledge, that by entering my name below, that this has the same force of an actual signature.
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