Patient Signature Form

Sierra Ambulance Service Inc/Claim Submission Authorization Form
Patient Name*
Date of Service*

MonthDayYear
Date
Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Sierra Ambulance Service Inc (SAS) has made public its Notice of Privacy Practices to the patient or other party via its website at www.sierraambulance.org/billing/ *A copy of this form is valid as an original*
Is the patient listed above capable of signing this document?*

The patient is physically and mentally capableThe patient is NOT physically able to signThe patient is NOT mentally able to sign
SECTION I - PATIENT SIGNATURE
The patient must sign here unless the patient is physically or mentally incapable of signing. NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.

I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by SAS now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by SAS, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to SAS any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to SAS. I authorize SAS to appeal payment denials or other adverse decisions on my behalf. I authorize and directany holder of medical, insurance, billing or other relevant information about me to release such information to SAS and its billing agents, the Centersfor Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by SAS, now, in the past, or in the future. I also authorize SAS to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information.

If the patient signs with an "X" or other mark, a witness should sign below.
Patient Signature or Mark*

Clear
Date*

MonthDayYear
Date
Witness Signature (only if patient signs by an "X")

Clear
Date

MonthDayYear
Date
Witness Address
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE
Complete this section only if the patient is physically or mentally incapable of signing.
Describe the circumstances that make it impracticable for the patient to sign:*
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by SAS now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered. Authorized representatives include only the following individuals: Patient's legal guardian Relative or other person who receives social security or other governmental benefits on behalf of the patient Relative or other person who arranges for the patient's treatment or exercises other responsibility for the patient's affairs Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient.
Representative Signature*

Clear
Date*

MonthDayYear
Date
Printed Name of Representative*
Authorized representatives include only the following individuals:*

Patient's legal guardianRelative or other person who receives social security or other governmental benefits on behalf of the patientRelative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairsRepresentative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient
Should be Empty:

Sierra Ambulance Service Inc/Claim Submission Authorization Form

SECTION I - PATIENT SIGNATURE

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE