Authorization for Treatment / Release of Information
Consent to Treatment: The patient and/ or authorized representative do hereby consent to any and all treatments which may deem advisable by the physician or Cardiac and Vascular Consultants, Inc. Patient Consent to Rx verification, Electronic Data Health Exchange (eEHX Interoperability). Each procedure and diagnostic study will be discussed in detail with patient before procedure is performed. Additional consent will be required at the time of procedure.
Assignment of Insurance Benefits: I assign payment directly to Cardiac and Vascular Consultants, Inc. Insurance Benefits otherwise payable to me. I understand that I am financially responsible for charges paid by this assignment. I will assist in the collection of my insurance should there be any delay in payment. I agree to actively participate in collecting Insurance payment for any claims unpaid after 30 days. If after 45 days the claim remains unpaid, I understand the balance will be due from me.
Medicare Patients: I certify that the information given by me in applying for payment under the XVIII if the Social Security is correct. I authorize Cardiac and Vascular Consultants, Inc. to release to the Health Care Financing Administration of its Intermediaries any information needed for this related Medicare claim, I hereby authorize payment directly to Cardiac and Vascular Consultants, Inc for medical benefits otherwise payable to me as beneficiary of the Medicare Program and such other payments as may be due by other third-party payers. I agree to execute such documents as may be necessary to apply for and obtain payment. I understand that such services as but limited to routine testing may not be covered by Medicare unless the Physician provides medical necessity.
Patient/ Guarantor Agreement: I understand that Cardiac and Vascular Consultants, Inc. is not in business expanding credit. Therefore, it is the policy of Cardiac and Vascular Consultants, Inc. to require payment in full at the time of service. If unable to pay due balance in full at the time of service, I agree to make prior arrangements with the Billing Department.
I understand that I am financially responsible for my/ the patient’s account with Cardiac and Vascular Consultants, Inc. regardless of my insurance benefits. I authorize copies of this form to be valid as the original.