I hereby authorize direct payment of surgical/medical benefits to Black River Health Services, Inc. for
services rendered. I understand that I am financially responsible for any balance no covered by my insurance.
I request payment of authorized Medicare/Medicaid benefits on my behalf for any services furnished
me by Black River Health Services, Inc. I authorize any holder of medical and other information about me to
release to Medicare/Medicaid and its agents any information needed to determine these benefits for related
I authorize Black River Health Services, Inc. to release or receive any medical or incidental information
about me that may be necessary for either medical care or processing of insurance claims.
I hereby grant permission for my child to be evaluated by the provider and receive appropriate
treatment including sutures and medications as deemed necessary (in my absence).
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