I, the undersigned patient and/or responsible party hereby jointly authorize this office, its agent and employees, to release and disclose all or any part of the patient’s medical records to any entity which is, or may be liable for all or part of the provider’s charges. I authorize the release of records necessary to assist in the reimbursement of benefits to which I may be entitled.
I authorize the release and disclosure, via fax machine, of any and all of my medical records to any other entity including but not limited to, referring physicians, hospitals, or health care providers which may be of assistance, in the opinion of this office, in the providing for the treatment of the patient.
I request and authorize that payment of Medicare/other insurance company benefits be made to Twin Cities Foot & Ankle Clinic, P.A. for any services furnished me by a provider of our clinic. Type your name below and this will be acknowledged as an electronic signature.
I understand that I am responsible for complying with the rules and regulations of my insurance company regarding Referral and Prior Authorization requirements. I agree to pay Twin Cities Foot & Ankle Clinic, P.A. for all charges for services not covered by Medicare or any insurance payer.