I hereby assign and request that payment of authorized insurance benefits, including Medicare if applicable, be made on my behalf to Doctors on Call for any medical services provided.
I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to Doctors on Call, the Centers for Medicare and Medicaid Services, any other insurance carrier with whom I have coverage.
I understand that I am financially responsible to Doctors on Call for any charges not covered by health care benefits, and I am only responsible for any deductible, co-pay or other amounts for services not covered by my insurance. I understand that Doctors on Call agrees to accept the payment made by Medicare and any other insurance coverage as its full charge. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim.
It is my responsibility to notify Doctors on Call of any changes in my health care coverage. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for services received.