Patient Information

Mailing Address
Physical Address

HITECH Act

If Under 18 years of age:

Insurance/Medicare/Medicaid Assignment of Benefits & Information Release

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 services.

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.

Parental consent for minors under 18 years

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).

Patient or Authorized Signature

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