SMA Consent Authorization Form

Please correct the errors described below.

Consent for Medical Treatment

I hereby authorization the personnel of Saluja Medical Associates to render to the patient
whose name appears on this form such care as they deem necessary and appropriate.

Authorization to Release Information

I hereby authorize Saluja Medical Associates to release my final diagnosis and other medical
information to the third party payers identified to determine benefits payable.

Assignment of Benefits

I hereby authorize direct payment to Saluja Medical Associates of any insurance, personal
injury protection or other benefits otherwise payable to the patient or me. The undersigned
acknowledges the responsibility of any co-insurance, deductible, or other sum not received
by the group from any third party source.

Guarantee of Payment

I acknowledge the financial responsibility for any health insurance deductible, coinsurance
or failure for any reason of any insurance carrier to pay the charges in full when rendered.
In the event that the account is referred for collection, I agree to pay all reasonable
collection and attorney fees required to collect any delinquent balance. I understand that I
will be responsible for any charges incurred by not providing the most current,
correct insurance information to Saluja Medical Associates.

Patient Certification, Authorization to Release Information

(Applies to Medicare patients only)

I hereby certify that the information given by me applying for payment under Title XVIII
and XIX of the Social Security Act of third party payers is correct. I authorize any holder of
medical or other information about me to release to the Social Security Administration or
its intermediaries or carriers any information need for this or a related Medicare Claim.

I certify that I understand the contents of this form:

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

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