Authorization to Bill Insurance Company
I request that payment of authorized Medicare benefits, or other insurance benefits, be made on my behalf for any services furnished to me by this provider. I authorize any holder of medical or other information about me to release to the Centers of Medicare and Medicaid Services and its agents, as well as to Life EMS, any information to determine these benefits for related services in the past, now or in the future. I hereby authorize payment directly to Life EMS, Inc. for ambulance services otherwise payable to me in the past, now of in the future. I further authorize release of any medical information necessary to process insurance claims. Please note if you are signing as a Power of Attorney or Legal Guardian, we must have a copy of the paperwork on file to accept your signature.
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Should be Empty: