Request for Signature Form

I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by the transporting agency 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 transporting agency, 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 agree to immediately remit to the transporting agency 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 the transporting agency. I authorize the transporting agency and its billing agent 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 the transporting agency and its billing agent, 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 the transporting agency now, in the past, or in the future. I also authorize the transporting agency and its billing agent to obtain medical, insurance, billing, and other relevant information about me from any party, database, or other source that maintains such information.