ASSIGNMENT OF BENEFITS FORM
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier/s, including Medicare, Medicaid, private insurance and any other health/medical plan, to issue payment checks directly to Porter Medical Associates for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount that is not covered/paid by insurance I further understand that all fees are due and payable on the date that services are rendered. I further understand that insurance is a contract between my insurance company and myself. Porter Medical Associates is not a third party to this contract, nor do we become involved in disputes regarding covered benefits and copays. I understand that it is my full responsibility to understand my insurance benefits. If coverage is denied I must contact my insurance for inquires. Our office involvement is strictly limited to supplying written documentation to facilitate claims processing.
CONSENT FOR MEDICAL TREATEMENT
I have requested medical services from Porter Medical Associates on behalf of myself and/or my dependents. I certify that Porter Medical Associates may perform any procedure for which the physician feels is in my best interest in medical intervention. I understand that some of the procedures performed may be considered as surgical or invasive procedures. Such procedures include, but are not limited to, trigger point injections, lab work, and IV therapy I do understand that I have the right to deny any procedures.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
The undersigned patient or legally authorized representative ("agent") of the patient acknowledges that he/she personally received a copy of the PORTER MEDICAL ASSOCIATES Notice of Privacy Policies on the date indicated below: