HILLTOP MEDICAL CLINIC
1093 HILLTOP DRIVE, REDDING, CA 96003
HILLTOP MEDICAL CLINIC WEST
2123 EUREKA WAY, REDDING, CA 96001
DEAR NEW MEDICARE PATIENTS – PLEASE READ AND SIGN FOR MEDICARE “SIGNATURE OF FILE” REQUIREMENTS.
DEAR ESTABLISHED MEDICARE PATIENTS – PER MEDICARE, WE ARE REQUIRED TO NOW USE THIS UPDATED FORMAT FOR OUR “SIGNATURE ON FILE” REQUIREMENT. THEREFORE, WE MUST HAVE EACH ESTABLISHED MEDICARE PATIENT SIGN ONE TO RETAIN ON FILE. THANK YOU VERY MUCH IN ADVANCE FOR YOUR COOPERATION REGARDING THIS 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.
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 on a non-assignment basis with Medicare. Therefore, Medicare should respond directly to me.
SIGNATURE OF PATIENT / LEGAL GUARDIAN — DATE