{"id":4041,"date":"2019-10-03T02:10:24","date_gmt":"2019-10-03T02:10:24","guid":{"rendered":"\/?page_id=4041"},"modified":"2019-10-11T01:32:55","modified_gmt":"2019-10-11T01:32:55","slug":"medical-release-insurance-assignment","status":"publish","type":"page","link":"https:\/\/www.washingtonnephrology.com\/index.php\/for-patients\/new-patient\/medical-release-insurance-assignment\/","title":{"rendered":"Medical Release\/Insurance Assignment"},"content":{"rendered":"<div class=\"et_d4_element et_pb_section et_pb_section_0  et_pb_css_mix_blend_mode et_section_regular et_block_section\" >\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_d4_element et_pb_row et_pb_row_0  et_pb_css_mix_blend_mode et_block_row\">\n\t\t\t\t<div class=\"et_d4_element et_pb_column_4_4 et_pb_column et_pb_column_0  et_pb_css_mix_blend_mode et-last-child et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_d4_element et_pb_text et_pb_text_0  et_pb_text_align_left et_pb_bg_layout_light\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_text_inner\"><h1><b>Medical Release Authorization and Insurance Assignment<\/b><\/h1>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>I hereby authorize Washington Nephrology Associates to apply for benefits on my behalf for covered services rendered. \u00a0I request payment from my insurance company to be made to the above named provider. \u00a0I understand and agree that, regarding of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.<span style=\"font-size: 14px;\">\u00a0<\/span><\/p>\n<p>I request that payment of authorized Medicare benefits be made to Washington Nephrology Associates for any services rendered. \u00a0I 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.<span style=\"font-size: 14px;\">\u00a0<\/span><\/p>\n<p>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. \u00a0Myself may revoke this authorization \u00a0at any time in writing.<\/p>\n<p>\u00a0<span style=\"font-size: 14px;\">I authorize \u00a0Washington Nephrology to release and\/or send medical information regarding my case to other consulting and\/or referring physicians.<\/span><\/p><\/div>\n\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_row et_pb_row_2  et_pb_css_mix_blend_mode et_block_row\">\n\t\t\t\t<div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_1  et_pb_css_mix_blend_mode et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_button_module_wrapper et_pb_button_0_wrapper  et_pb_module \">\n\t\t\t\t<a class=\"et_pb_button et_d4_element et_pb_button_0 et_pb_bg_layout_light et_block_module\" href=\"\/index.php\/for-patients\/new-patient\/\">Back<\/a>\n\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_2  et_pb_css_mix_blend_mode et_block_column et_pb_column_empty\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_3  et_pb_css_mix_blend_mode et_block_column et_pb_column_empty\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_4  et_pb_css_mix_blend_mode et_block_column et_pb_column_empty\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_5  et_pb_css_mix_blend_mode et_block_column et_pb_column_empty\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div><div class=\"et_d4_element et_pb_column_1_6 et_pb_column et_pb_column_6  et_pb_css_mix_blend_mode et-last-child et_block_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module et_d4_element et_pb_code et_pb_code_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_code_inner\"><div class='printomatic pom-default ' id='id8069'  data-print_target='article'><\/div><\/div>\n\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\n\t\t\t<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":666,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-4041","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/4041","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/comments?post=4041"}],"version-history":[{"count":0,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/4041\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/pages\/666"}],"wp:attachment":[{"href":"https:\/\/www.washingtonnephrology.com\/index.php\/wp-json\/wp\/v2\/media?parent=4041"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}