Medicare Signature on File
Dear Medicare patients – we are required to now use this updated format for our “signature on file” requirement..
I request the payment of authorized Medicare benefits be made either to me or on my behalf to R.P.C.M.G., Inc. dba Hilltop Medical Clinic / Hilltop Medical Clinic West, for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to CMS Centers for Medicare & Medicaid Services, any information needed to determine these benefits payable to related services.
Please be advised that you may be treated by one of our Mid-Level Practitioners (N.P or P.A.) at Hilltop Medical Clinic/ Hilltop Medical Clinic West. It is a requirement of Medicare that if you are seen by one of these Medical Providers as a patient with no M.D. or D.O. “on site” we bill your services accepting assignment for that particular office visit. In this situation, we would bill Medicare and not require payment at the end of your visit, any payments made would be sent to Hilltop Medical Clinic/ Hilltop Medical Clinic West by Medicare.
You may receive a statement for any balance unpaid by Medicare, such as copay or deductible amounts. Our usual office policy of Non-Assignment and Payment in full would be followed if you are seen by our M.D., D.O. or Mid-Level practitioner when a physician is “on-site”.
I understand my signature requests that payment be made and authorize release of medical information necessary to pay claim. If other health insurance coverage is indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. Per billing law requirements, my claim will be submitted by this office to Medicare for processing. I understand this office is primarily on a non-assignment basis with Medicare. Therefore, Medicare will respond directly to me.
Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and effect.