I hereby authorize my insurance company to pay directly to South Florida Rheumatology any and all medical and/or surgical benefits otherwise payable to me for their professional services.
I acknowledge that I am personally responsible and liable to South Florida Rheumatology for any and all medical and/or surgical fees billed by them. Should South Florida Rheumatology accept payment by direct assignment from Medicare or any other insurance company, I understand that I am responsible and liable for any and all deductable expenses and “co-insurance” not covered by Medicare or my primary insurance company. I understand that any overpayment on my part will be refunded to me promptly.
I acknowledge that I am personally responsible for full payment of all “non-covered” services, and I am responsible for all return checks and I agree to pay a $50.00 per check per incident fee for each returned check. If I am placed into collections or I my account goes to litigation, I agree to be responsible for all collection and attorney’s fees.
I hereby authorize release of all medical records to my primary care physician, to other physicians to whom I am referred for my care, and to my insurance company or plan.