*If other than patient please fill in the following information*
*If other than patient or primary insurance subscriber please fill in the following information*
I hereby authorize my provider to furnish my insurance company or its representative or permit my
insurance company or its representative to review any information requested with respect to any illness or accident, medical history or copies of hospital and medical records. A photostatic copy of this authorization shall be considered as valid as the original. I hereby authorize payment directly to
my provider for this illness or injury, of the provider’s benefits otherwise payable to me, but not to exceed my indebtedness to said provider. I agree to pay the provider for all my charges whether or not covered by this assignment. The responsible party hereby agrees that the provider’s office or the
party responsible for the billing of these services may check credit with any source to obtain credit information. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This release may include information which
may be considered a communicable or venereal disease which may include, but are not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency syndrome (AIDS). I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above
and grant the request of authorizations.
I have been notified that I may receive services from the Advanced Practice Provider at this location.
I authorize Salina Regional Health Center, and all affiliates, health care providers to provide verbal information concerning my health care to those that I have listed below while I am a patient. Verbal requests for information from other friends, family,
caretakers, concerning my health care will not be disclosed without an additional authorization from me.
(Exception: Health Information may be disclosed without authorization in an emergency situation or if SRHC determines that
the disclosure is in my best interest and the information disclosed is limited to those persons involved in my care).