Medical Release Authorization and Insurance Assignment
I hereby authorize Washington Nephrology Associates to apply for benefits on my behalf for covered services rendered. I request payment from my insurance company to be made to the above named provider. I understand and agree that, regarding of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.
I request that payment of authorized Medicare benefits be made to Washington Nephrology Associates for any services rendered. I authorize any holder of medical information about me to be release to the Health Care Financing Administration and its agents, any information needed to determine these benefits or the benefits payable for related services.
I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled. Myself may revoke this authorization at any time in writing.
I authorize Washington Nephrology to release and/or send medical information regarding my case to other consulting and/or referring physicians.