Kidney and Hypertension Consultants

Patient Information

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RECORDS RELEASE: I hereby authorize the release or any information. including medical and billing information to my referring doctor and my insurance company. I understand that you may be transmitting my medical records electronically and authorize you to do so. If another party in error receives them. I absolve Kidney and Hypertension Consultants, Inc. of any and all liability to such submission of said records.

GUARANTEE OF ACCOUNT: I understand that medical insurance policies are an arrangement between an insurance carrier and myself. I understand I am financially responsible for any balance not covered by my insurance company. I understand that I am responsible for any co-payments, deductibles, and fees for non-covered services. I understand I am responsible for any referrals and/or authorizations required by my insurance company.

ASSIGNMENT OF BENEFITS: I hereby authorize Medicare benefits and other insurance benefits to be paid on my behalf to KIDNEY AND HYPERTENSION CONSULTANTS, INC., for any services furnished me by that physician/clinic/supervisor. I authorize any holder of the hospital or medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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