Assignment and Release
I, the undersigned, have insurance coverage with the insurance company(ies) indicated above
and assign directly to SICHC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submission.
I request that payment of authorized benefits be made either to me or on my behalf to SICHC for any services furnished to me by my physician/nurse practitioner.
I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to the related services.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare assigned cases, the physician/nurse practitioner agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.
Social History / Income Assistance
The following questions may seem difficult to answer, but are important for us to know, so we can properly screen all our patients for their health care needs. Additionally, we have many programs to provide financial assistance and appreciated your answers to these questions.
Medical History and Medications
Immunization History and Exposure
General Health Maintenance and Planning
Family Medical History
Please check the box that corresponds to the condition and the family member with that condition.