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Authorized Signature Form

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PATIENT SIGNATURE

AUTHORIZED REPRESENTATIVE SIGNATURE

Ambulance Provider Name:

Patient Name

Phone/Mobile

Transport Date

Privacy Practices Acknowledgment: by signing below, the signer acknowledges that the above listed ambulance provider provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient.*A copy of this form is valid as an original*

PATIENT SIGNATURE

The patient must sign here unless the patient is physically or mentally incapable of signing. NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.

I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by the above-listed ambulance service now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by the above-listed ambulance service, 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 the above-listed ambulance service 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 the above-listed ambulance service. I authorize the above-listed ambulance service to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to the above listed ambulance service and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by the above listed ambulance, now, in the past, or in the future. I also authorize the above-listed ambulance service to obtain medical, insurance, billing, and other relevant information about me from any party, database, or other source that maintains such information.

AUTHORIZED REPRESENTATIVE SIGNATURE

Complete this section only if the patient is physically or mentally incapable of signing.

Describe the circumstances that make it impractical for the patient to sign

I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by the above listed ambulance service now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.

Authorized representatives include only the following individuals:

Authorized representatives include only the following individuals:

Patient’s legal guardian

Relative or other person who receives social security or other governmental benefits on behalf of the patient

Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs

Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but furnished other care, services, or assistance to the patient

Patient Signature or Mark

Date

Representative Signature

Date

Serving: Illinois and Iowa