I accept treatment and transport services provided by Instamed EMS. I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by Instamed EMS now, in the past, or in the future. I understand that I am financially responsible for the services and supplies provided to me by Instamed EMS, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance.
I understand my insurance may require Prior Authorization for the scheduled transport and I will provide this Authorization or be responsible for paying the balance including deductibles and/or Co pay but not limited to the entire balance via a Credit Card. I agree to immediately remit to Instamed EMS 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 Instamed EMS. I authorize Instamed EMS to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or other relevant documentation about me to release such information to Instamed EMS and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payors 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 Instamed EMS, now, in the past, or in the future.
I hereby acknowledge receipt of the Instamed EMS Notice of Privacy Practices.
