AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Hilltop Medical / Hilltop Medical Clinic West to furnish my insurance company(ies), and/or their Attorney or an Industrial Related Injury insurance company, and/or their Attorney or collection agency, with any and all information which said parties my request to be provided with, concerning my office visits here.
WAIVER OF CONFIDENTIALITY: If the account is submitted to an attorney or collection agency, goes to court or is reported to a credit reporting agency, the fact that you received treatment here may become a matter of public record.
ASSIGNMENT OF BENEFITS: I hereby assign Hilltop Medical / Hilltop Medical West all money to which I am entitled for medical and/or surgical expense related to the services reported herein, but not to exceed my indebtedness to Hilltop Medical Clinic / Hilltop Medical Clinic West. It is understood that any money received from the insurance company(ies) over and above my debt will be refunded to me, or back to my insurance company, when my bill is paid in full. I understand that I am financially responsible to Hilltop Medical / Hilltop Medical West for charges not covered by this assignment.
EFFECTIVE DATE: 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.
X___________________________________________ DATE:_______________
SIGNATURE OF PATIENT/LEGAL GUARDIAN
**MEDICAL RECORDS RELEASE**
AUTHORIAZATION TO DISCLOSE HEALTH INFORMATION
EXPLANATION: If you are a parent/legal guardian of a minor (under 18 years old) it is understood that you may access all health and/or billing information. If you’re an adult and over the age of 18 and your significant other or parents handle your health and/or billing issues for you – you may want to consider authorizing that person by putting their name down.
Hilltop Medical / Hilltop Medical West must have authorization from the patient (by law) to speak to a spouse or parents of children that are 18 years of age about each others health and/or billing information.
I authorize Hilltop Medical / Hilltop Medical West to release any health and/or billing information to the following individual (other than parent of a minor):
________________________________________________________DATE:_____________
Name of person authorized to access my health/billing information (You may leave this area blank)
I understand that authorizing the disclosure of health/billing information is voluntary. I can choose not to designate anyone to release my records to. I understand I have the right to revoke this authorization in writing at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization.
EFFECTIVE DATE: 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.
X___________________________________________ DATE:_______________
SIGNATURE OF PATIENT/LEGAL GUARDIAN
