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.