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Spouse or Significant Other or Parent/Guardian Information
If entering parent / guardian information, complete both name sections fully. |
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Emergency Contacts
I understand it may be necessary to discuss my medical information with persons listed below.
I authorize you to contact the following persons on my behalf.
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Assignment of Benefits
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I/patient hereby authorize my signature on all insurance and Medicare claim forms at the office of Women's Health Center for payment directly to Dr. Mark F. Morrison or to Dr. Paul W. Morrison for services rendered to me/patient. I authorize this office to release all information with respect to myself or any of my dependents which is necessary or required for the processing of claims under said insurance policy. I/patient understand that I am personally responsible for charges incurred whether my insurance pays or not. I/patient also understand that I am responsible for any attorney fees and court costs incurred in collecting any unpaid balances for services I/patient received. I agree that this statement applies to all current and future claims. |
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