Authorization to be Paid:
The undersigned authorizes Southeastern Spine Institute to contact, furnish and discuss with insurance companies all medical and financial information pertaining to the medical services that may be required to be paid or collected for the care received. The undersigned irrevocably assigns and transfers to Southeastern Spine Institute all rights and interest in benefits that the patient may have under any policy of insurance including all medical, third party liability, automobile coverage, workers’ compensation benefits, or any other insurance or benefits. The undersigned directs that any such insurance company or payer make payment of such benefits directly to the Southeastern Spine Institute. By signing below, the undersigned agrees to be financially responsible for amounts not covered by insurance.
Third Party Liability Cases:
If the patient’s illness is a result of an accident, The undersigned understands that he/she has the option to request Southeastern Spine institute to bill Health Insurance or pursue payment from the auto or accident insurance of the person responsible for the accident. In accordance with federal regulations, Southeastern Spine will file claims for Medicare or Medicaid beneficiaries whose illness is a result of an accident caused by a third party or whose claims may be paid by a third party, only as a last resort. In all cases, Southeastern Spine reserves the right to file claims to health insurance on the advice of our attorney. If Southeastern Spine is asked to bill health insurance, the undersigned understands that the patient is responsible for paying all deductibles and co-pays at the time of service.