CONSENT FOR TREATMENT, RELEASE OF INFORMATION, AUTHORIZATION
& ASSIGNMENT OF BENEFITS
I consent to treatment necessary to the care which has been discussed and directed by the provider.
I authorize the release of all medical records to specialists and/or consulting physicians if applicable to my care and condition.
I authorize any holder of medical or other information about me to release to the Social Security Administration, Health Care Financing Administration, its intermediaries, its carriers, or any other insurance carrier any information needed for this or any other related claim to be processed. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to me or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any party who may be responsible for paying for my treatment.
I further authorize and request that insurance payments be directed to Trident Heart and Vascular