ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize direct payment of my insurance benefits to Terren D. Klein MD, PA for the services rendered to me or my dependents by the physician or under his supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Terren D. Klein MD, PA is unable to collect from my insurance carrier for whatever reason.
MEDICARE/MEDICAID/CHAMPUS/TRICARE INSURANCE BENEFITS:
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct the payment of my or my dependent’s authorized benefits to be made directly to Terren D. Klein MD, PA on my behalf.
AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:
I hereby authorized Terren D. Klein MD, PA to release any of my or my dependent’s medical or incidental non-public personal information that may be necessary for medical evaluations, treatment, and consultation or the processing of insurance benefits.
AUTHORIZATION TO MAIL, PHONE CALL OR E-MAIL:
I hereby authorize Terren D. Klein MD, PA representative to mail, call or e-mail with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, claims, insurance benefits and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying Terren D. Klein MD, PA to that effect in writing.
AUTHORIZATION TO REQUEST LAB/X-RAY/MRI/EMG OR OTHER DIAGNOSTIC RESULTS:
I hereby authorize Terren D. Klein MD, PA to request my or my dependent’s lab, x-ray, MRI, EMG or other diagnostic results that may be necessary for medical evaluations, treatment, and consultation or for the processing of claims.
CONSENT TO TREATMENT:
I hereby consent to and authorize the performance of all treatments, surgeries, testing and medical services deemed advisable by the physician and staff of Terren D. Klein MD, PA to me or to my dependent of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I fully understand this agreement and consent will continue until cancelled by me in writing.