I hereby authorize Greater Michigan Orthopedics to release any information regarding my diagnosis and treatment to above stated insurance co, workman's comp carrier and/or physician. I request and authorize payment of medical benefits to Greater Michigan Orthopedics or the providing physician. I also release my medical records to the above named insurance companies, referring physician and myself upon request. If payment is not received within a reasonable length of time, the bill will then become my responsibility. I agree that if I carry an insurance that requires a referral (HMO), I will be responsible to obtain a referral from my primary care physician. I agree if I do not carry health insurance, I am responsible for all services rendered by the treating physician.
We will collect your signature in the office.
If you want your medical information to be released to someone in your family, please list their name(s) below. If their name is not written below, information will not be released.
I request the payment of authorized Medicare benefits be made on my behalf to Greater Michigan Orthopedics for any services by that physician/clinic. I authorize any holder of hospital or medical information about me to release to the Healthcare Financing Administration and its agents any information needed to determine the benefits payable for related services. I permit a copy of this authorization be used in place of the original.
One fine body…