HILLTOP MEDICAL CLINIC
1093 Hilltop Drive, Redding, CA  96003

 

DEAR NEW MEDICARE PATIENTS -PLEASE READ AND SIGN FOR MEDICARE "SIGNATURE ON FILE" REQUIREMENTS.

DEAR ESTABLISHED MEDICARE PATIENTS - PER MEDICARE, WE ARE REQUIRED TO NOW USE THIS UPDATED FORMAT FOR OUR "SIGNATURE ON FILE" REQUIREMENT.  THEREFORE, WE MUST HAVE EACH ESTABLISHED MEDICARE PATIENT SIGN ONE TO RETAIN ON FILE!  THANK YOU VERY MUCH IN ADVANCE FOR YOUR COOPERATION REGARDING THIS REQUIREMENT.

**SIGNATURE &  (HIC) MEDICARE #   -TO BE DONE AT THE  FRONT COUNTER ELECTRONICALLY

I request the payment of authorized Medicare benefits be made either to me or on my behalf to R.P.C.M.G., Inc., dba HILLTOP MEDICAL CLINIC, for any services furnished to me by that physician or supplier.  I authorize any holder of medical information about me to release to C.M.S. formerly Health Care Financing Adminstration and its agents, any information needed to determine these benefits payable to related services.

I understand my signature requests that payment be made and authorize release of medical information necessary to pay claim.  If other health insurance coverage is indicated in Item
9 of the HCFA-1500 claim form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.  Per billing law requirements, my claim will be submitted by this office to Medicare
for processing.  I understand this office is on a non-assignment basis with Medicare. 
Therefore, Medicare should respond directly to me.

**SIGNATURE -TO BE DONE AT THE  FRONT COUNTER ELECTRONICALLY