Form 1b - Authorization for Release of Information


Mercer – Bucks Orthopaedics Compassionate & Comprehensive Patient Care

Form 1b - Personal & Insurance Information

You may fill out form on line or print & bring with you to your appointment.

AUTHORIZATION FOR RELEASE OF CONFIDENTIALITY & MEDICAL INFORMATION
*Last Name:
*First Name:
*Date of Birth:
*Social Security #:
This authorization will authorize Mercer Bucks Orthopaedics to furnish all information they may have regarding my condition, while under their observation or treatment, to any party who may be responsible for payment to Mercer Bucks Orthopaedics, including the history obtained, X-ray and physical findings, diagnosis and prognosis. In addition to release of information as authorized and in the interest of confidentiality with HIPAA (Health Insurance Portability and Accountability Act), your careful consideration and acknowledgement as to whom we may release information to on your behalf is required. This would pertain specifically to personal relations, i.e. family, friends, etc. I authorize the release of medical information (health and demographics) as it pertains to my care only to the following. (You may contact our office at any time should you wish to make changes to this authorization}
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
ASSIGNMENT OF INSURANCE BENEFITS
I assign the group physician benefits herein specified and otherwise payable to me to Mercer Bucks Orthopaedics, but not exceeding Mercer Bucks Orthopaedics charge for this period of treatment. I authorize and request that payment be made directly to Mercer Bucks Orthopaedics. I understand and agree that regardless of my insurance coverage, I am financially responsible to Mercer Bucks Orthopaedics for charges not covered by my insurance company or this authorization. This assignment is acceptable.
MEDICARE AND MEDIGAP ASSIGNMENT OF BENEFITS
I request that payment or authorized Medicare and/or Medigap benefits to be made either to me or on my behalf to Mercer Bucks Orthopaedics for any services furnished by the physician/supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I further authorize any holder of Medicare and/or Medigap information about me to release to Mercer Bucks Orthopaedics any information needed to determine benefits payable or related services. I understand that when I click the Submit button, this is the equivalent of my personal signature and requests that payment be made and authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, Mercer Bucks Orthopaedics agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance and non-covered services.
*Date:

Home • Up • Form 1 - Personal & Insurance Information • Form 1b - Authorization for Release of Information • Form 2 - Medical History • Form 2b - Medical History • Form 3 - Non Auto Accident


	3120 Princeton Pike · Lawrenceville, NJ 08648 (609) 896- 0444 · (609) 896- 0290 Fax info@mercerbucksortho.com Copyright©2005 · Mercer-Bucks Orthopaedics · All rights reserved Web site designed and maintained by Computer Imaging & Applications · Contact Webmaster