I hereby authorize the release of my medical information, including Protected Health Information (PHI) concerning my treatment to any third-party payor, inclunding but not limited to health plans and insurers, Medicare, Medicaid, TRICARE and CHAMPVA for payment purposes. Further, I authorize payment of any insurance or other benefits that may be made on my behalf by any party, including any health plan or insurer, Medicare, Medicaid and any other federal or state healthcare programs, directly to Florida Digestive Specialists. I understand that this assignment of benefits does not relieve me of my obligation to pay Florida Digestive Specialists for any charges not covered by this assignment or not paid by insurance or healthcare benefits.
I understand and agree, whether I sign as agent or patient, that I am responsible for and guarantee payment of any charges incurred for the services provided to the patient by Florida Digestive Specialists. I further understand and agree that I will be responsible for payment of any deductible, co-payment, co-insurance amounts, or any charge that is not covered or paid by insurance, healthcare benefits or third-party payors.
I authorize Florida Digestive Specialists to release the patient's medical information, including HIV testing and treatment information, to other parties (which may include include providers, payors, business associates or other entities) for the purpose of tratment, payment or healthcare operations.
I authorize Florida Digestive Specialists to retrieve and obtain my Protected Health Information from any past provider's office, institution or facility for the purpose of the continuation of medical treatment.