(Enter name of person FINANCIALLY responsible for your account)
INSURANCE COMPANY – INCLUDING MEDICAID
Assignment and Release
I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.
Please complete the information below if you would like to receive the flu vaccine from PanCare of Florida, Inc.
Consent for Treatment
I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.
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