Insurance Authorization

 

 

 

 

 

 

Please Provide Primary and Secondary Insurance Information Below

 

 

Commercial Insurance
(including Secondary Insurance, Auto Insurance – if auto related, Workman’s Compensation – if work related, HMO and PPO)

POLICY #1

 

 

 

 

POLICY #2

 

 

 

 

Payment Information

 

 

 

Cardholder’s Information

 

 

 

 

 

 

 

PLEASE READ the following documentation before providing your signature

I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to Lafayette Ambulance and Rescue Squad Inc. (Lafayette Ambulance), for any services provided to me by Lafayette Ambulance now or in the future. I understand that, unless I am a Pennsylvania Medical Assistance Recipient, I am financially responsible for the services provided to me by Lafayette Ambulance, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Lafayette Ambulance, any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Lafayette Ambulance. I authorize Lafayette Ambulance to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to Lafayette Ambulance and its billing agents, and/or the Centers for Medicare and Medicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by Lafayette Ambulance, now or in the future. A copy of this form is as valid as an original.

Privacy Practices Acknowledgment: by signing below, I acknowledge that I have received the Lafayette Ambulance Notice of Privacy Practices. I further understand my privacy rights concerning protected health information (PHI) about me and I agree to consent fully to the uses and disclosures of PHI by Lafayette Ambulance as more fully described in the Lafayette Ambulance Notice of Privacy Practices.

 

 

 

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