I/we the below named patient, insurance subscriber and/or legal representative authorize University Diagnostic Institute Winter Park, PLLC, to bill the below-named insurance company or companies or any other insurance company required to pay benefits for the provided services to include any possible secondary insurance, automobile insurance. or workers compensation insurance for such medical services. I/we hereby assign the benefits payable from the below named insurance company or companies or any other insurance company required to pay benefits for the provided services to University Diagnostic Institute Winter Park, PLLC. assignment shall include the right for University Diagnostic Institute Winter Park, PLLC to file lawsuit on my behalf in order to collect any unpaid insurance benefits including personal protection benefits. In connection with the foregoing, I/we hereby authorize University Diagnostic Institute Winter Park, PLLC to release to the below-named insurance company or companies any information needed for collection of benefits on my/our behalf. Further I/we agree to forward any insurance payments paid to patient and/or subscriber for services rendered by University Diagnostic Institute Winter Park, PLLC. This assignment shall include the right for University Diagnostic Institute Winter Park, PLLC to obtain an unredacted copy of the personal injury protection payment log from the below named insurance company.
MEDICARE/MEDICAID CERTIFICATION FOR PAYMENT
I/we certify the information provided by me/us in applying for payment under Title XVII and/or Title XIX of the Social Security Actis correct. I/we authorize University Diagnostic Institute Winter Park, PLLC and its affiliated physicians to release to the Social Security Administration or its intermediaries or carriers any information needed for Medicare claims filed by them on my behalf. I request the payment to authorized benefits to be made on my behalf. Additionally. I/we assign benefits payable for physician services to the physician, physician group or organization furnishing the services. Further I/we request the above authorization to apply to the secondary or Medigap policy as reflected on page one.
Notwithstanding the foregoing, in consideration of services provided by University Diagnostic Institute Winter Park, PLLC to the patient named below, unless the services are covered by Medicaid, Medicare (or a Medicare Replacement product), or an HMO, or unless the applicable insurance contract provides otherwise, the undersigned is/are responsible for payment of all charges that arenot paid by the insurer or other payor. I/we understand that insurance forms will be completed by University Diagnostic Institute Winter Park, PLLC (hereinafter also referred to as "UDI") for my/our convenience. but that payment to UDI is due at the time of services are rendered. I/we also agree that if I/we have an unpaid balance and a patient refund is owed to me/us, UDI may apply the patient refund to the unpaid balance. I/we further agree that if any amount remains outstanding for a period of 120 days, that balance will be considered delinquent and turned over to a collection agency. I/we authorize the release of financially identifiable information concerning my account, including charges billed, payment made. and interest charges assessed, etc. to UDI's collection agency or collection attomey should collection procedures as described become necessary. In case of suit, I/we agree the venue shall be in Orange County. FL. I give my express permission to University Diagnostic Institute Winter Park, PLLC and its Affiliates or contractors to contact me for any purpose at the current or any future numbers that are provided for my landline telephone, cellular telephone or any wireless device including the use of automated dialing equipment, prerecorded voice, or text messages.
I/we, the below named patient and/or legal representative, hereby authorize University Diagnostic Institute Winter Park, PLLC to release any information to the Social Security Administration, its intermediaries or other government agencies, insurance carriers or legal counsel concerning diagnosis and treatment claims filed by the physician or their organization on my behalf.