AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS
I understand that Sonoran Spine Center, PC. bills my insurance carrier as a courtesy, but I am responsible for paying all changes incurred by me and/or my dependents. I understand that if my account is turned over for collections, I will incur a collections fee.
I hereby assign all medical and surgical benefits to which I am entitled. I hereby authorize my insurance carrier(s), including Medicare, any private or public insurer and any other insuring party to issue payment directly to Sonoran Spine Center, PC for all medical expenses for me and/or my dependents regardless of insurance benefits, if any.
I authorize Sonoran Spine Center, PC to release any and all information regarding my condition and care to myself, my insurance carriers, or other healthcare providers or referring physician associated with my care.
I have read and understand this form.