I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.

I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company 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 Insurance Company.

I have the right to revoke this authorization at any time. My revocation must be in writing, signed by me or my legal representative, and delivered to Peninsula Radiation Oncology Center, Attn: HIPAA Compliance Officer, via mail or in person. It will be effective only when Peninsula Radiation Oncology Center physically receives it. The information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under federal privacy regulations.

Please note, this form expires one year after signed. You will be asked to complete this form annually.

I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.

I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company 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 Insurance Company.