Iauthorize the doctor, Dr. David Masel, MD, to examine me (or the patient I am legally responsible for) and to do any x-rays or
other diagnostic tests that may be needed to make a diagnosis and to provide treatment. I consent to necessary office or other outpatient treatment after being properly informed of alternatives, benefits, and risks.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I authorize Dr. David Masel, MD to release to any insurance company, health plan, or government agency such medical information that may be required to process my claim for payment of this medical bill. I also authorize Dr. David Masel, MD to release appropriate medical information to any doctor, hospital, or other health care facility that has or will participate in my (the patient's) care. I authorize a photocopy, facsimile, or other electronic transmission of the above Assignments, Authorizations, and Releases to be used in place of the original until/unless I send written notice to the contrary to the offices of Dr. David Masel, MD. I further authorize any other doctor, hospital, or health care facility to release to Dr. David Masel, MD office any medical information concerning my (the patient's) illness or injury.
FINANCIAL AGREEMENT: I agree to pay all professional fees charged by Dr. David Masel, MD for my (the patient's) care, irrespective of any insurance benefits to which I may be entitled, except if Dr. David Masel, MD has agreed to accept insurance benefits as full payment for covered services in accordance with federal or state law (e.g. Medicare, Medicaid) or by contract with a prepaid health plan or managed-care plan, and provided such insurance benefits are paid within 60 days of claims submissions, and provided there is no recovery from a third-party negligence lawsuit (see Injuries and Third-Party Negligence, below Ultimately, it is your responsibility to understand the coverage that you pay for in a monthly premium to your carrier. If an employer or its carrier denies a claim for payment for a work-related injury, or if a prepaid health plan, managed-care health plan, or Medicare, considers certain services ineligible or uncovered services, then you (patient) agree to pay for those services. It is understood that claims for services remaining unpaid 60 days after claims submission shall be presumed ineligible for insurance reimbursement, and you (patient) shall pay for those services. If patient is a minor - the parent/guardian who requests treatment for a child will be responsible for all fees.
INJURIES AND THIRD-PARTY NEGLIGENCE: I understand and agree that if Dr. David Masel, MD has granted discounts from its usual fees for any reason, including its participation in prepaid or managed-care health plans, and if I (the patient) recover(s) any monies as the result of any judgment, award, or settlement of any lawsuit arising from treated injuries or illness, then I shall give a lien to Dr. David Masel, MD against such monetary recovery in the full amount of such discounts.
DELINQUENCY: If my (the patient's) account becomes delinquent, I understand that Dr. David Masel, MD, at its sole discretion, may refer to a collection agency or an attorney as allowed by law.
INSURANCE ASSIGNMENT: I authorize my insurance company or third-party payer to whom a claim for payment has been submitted to pay any eligible benefits directly to Dr. David Masel, MD. I hereby authorize payment to go directly to Specialty (and/or Medicare) and understand Care Clinics for medical benefits payable by insurance company that I am responsible for any charge not covered by the terms of my insurance policy. I hereby assign Dr. David Masel, MD full rights to represent my (the patient's) interests in any complaints of appeals for denial of benefits or reimbursement to the Texas Department of Insurance (State Insurance Commissioner I hereby authorize said assignee Dr. David Masel, MD to furnish these agencies such information as may be necessary to support such complaints or appeals.
I agree I cannot revoke the FINANCIAL AGREEMENT or the INSURANCE ASSIGNMENT at any time while any portion of the medical bill remains unpaid. I have read, understand, and do hereby agree to the terms of the forgoing Assignments, Authorizations, and Releases. I also certify that the PATIENT INFORMATION I have provided is true and accurate to the best of my knowledge.