PLEASE READ AND SIGN THE FOLLOWING.
WHEN IT IS COMPLETED RETURN IT TO THE OFFICE RECEPTIONIST.
|CONSENT TO PAY AGREEMENT|
|The ___________________________________ exam that you are about to have may or may not
be covered by the Medicare Program. We will do everything possible to assist you in collecting
the payment for your claim, including rebilling the Medicare Necessity Appeals Board. I agree
to pay if Medicare does not.|
NOTE: Must be signed by the Beneficiary or the Beneficiary's legally appointed representative.
|MEDICARE SIGNATURE AUTHORIZATION|
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductable, coinsurance, and noncovered services. Coinsurance and the deductable are based upon the change determination of the Medicare carrier.
Updated: January 11, 1998