The Patient or Guarantor is responsible for payment in full or co-payment is expected at the time of service. Services provided that are not a covered benefit of your health plan will be your responsibility.
AUTHORIZATION, ASSIGNMENT, AND RESPONSIBILITY OF ACCOUNT
I hereby authorize Coquille Valley Hospital Clinic to release to the above insurance companies &/or carriers any medical or other information needed for claims
reimbursement. I hereby assign, transfer, and set over to Coquille Valley Hospital Clinic all my rights, title, and interest to medical reimbursement benefits under my
insurance policy with the above documented insurance companies. I hereby acknowledge and accept responsibility for payment in full of all services rendered to me by Coquille Valley Hospital Clinic.