I give my authorization to release medical records to assist in the processing of my insurance claims. I also authorize Michigan Medical Billing Services, LLC to receive the information needed regarding my account to bill my insurance and for payments of my claims to be mailed directly to my provider and/or providers office named above for providing my services. I understand that I am completely responsible for any charges incurred and that billing my insurance does not guarantee payment of the claim(s). If the provider of service does not receive payment in a timely fashion, I understand that I may receive a bill for services rendered. I have also received a copy of the HIPAA policies and practices from my provider.
If the form is signed by the Provider or Providers Office's Staff they are confirming that the client has signed forms indicating the above information and they have that information on file in their office.