Signature Form

Signature Form

SouthBridge Emergency Medical Services, Inc. Signature/Claim Submission Authorization Form – Version 2.2
Patient Name*

First NameLast Name
Transport Date*

MonthDayYear
Date
- SECTION I - PATIENT SIGNATURE
  
  The patient must sign here unless the patient is physically or mentally incapable of signing. I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by SBEMS 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 SBEMS, 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 SBEMS 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 SBEMS. I authorize SBEMS to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to SBEMS and its billing agents, the Centers for 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 SBEMS, now, in the past, or in the future. I also authorize SBEMS to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains
- 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...
- Patient Signature
- Date Signed
  
  MonthDayYear
  Date
- 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 impractical 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 SBEMS 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 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
- Signature
- Name of Person Signing for Patient
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Should be Empty:

Signature Form

SECTION I - PATIENT SIGNATURE

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE