Multiple Consent Form Patient Name Date of Birth MM DD YYYY Notice of Financial Consents: This authorization is valid and in effect until such time I withdraw it in writing or in person. In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided. • I understand that I am financially responsible for my health insurance deductible, co-insurance or non-covered service. • Co-payments are due at time of service. • If I am uninsured, I agree to pay for the medical services rendered to me at time of service.. • I request payment of Government benefits to this provider for the care they rendered; I authorize payment of medical services from my insurance to this provider. For Medicare Members: I request the payment of authorized benefits be made either to me or on my behalf to Friends of Family Health Center for any services furnished me by my physician. I authorize any holders of medical information about me to release to the health care financing administration and its agents any information needed to determine benefits or the benefits payable for related services. I hereby authorize Medicare to furnish to the above named health center any information regarding my Medicare claims under Title XVIII of the Social Security Act. A copy of this signature is as valid as the original. For Commercial Insurance Members: I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me, the doctor, or group indicated on the claim. I understand I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original. Signature of Patient or Patient's Representative Signature of Patient or Patient's Representative Consent to Leave Messages: I hereby authorize Temple Care & Wellness Health Advocates, its representatives, physicians, and staff to leave messages related to my healthcare on a recorder at the following phone number(s): Home Cell Signature of Patient or Patient's Representative Signature of Patient or Patient's Representative Photo Consent I understand that I may revoke this authorization at any time, by notifying Innovare Health Advocates in writing. However, if I choose to do so, I understand that my revocation will not affect any actions taken by Temple Care & Wellness Health Advocates before receiving my revocation. I understand that I may refuse to sign this authorization and that my refusal to sign in no way affects my treatment, payment and enrollment in a health plan or eligibility for benefits. I hereby authorize Innovare Health Advocates and their staff to capture my hotograph to be attached to my chart. Signature of Patient or Patient's Representative Signature of Patient or Patient's Representative Thank you for filling out your information!
