I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by EMS now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by the EMS, regardless of my insurance coverage, and, in some cases, may be responsible for an amount in addition to what my insurance paid. I agree to immediately remit any payments that I receive directly from insurance or any source whatsoever for the services provided to me, and I assign all rights to such payments to EMS. I authorize EMS to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to EMS and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by EMS, now, in the past, or in the future. I also authorize EMS to obtain medical, insurance, billing, and other relevant information about me from any party, database, or other source that maintains such information.
The patient must sign here unless the patient is physically or mentally incapable of signing.