(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.
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.