AUTHORIZATION TO RELEASE INFORMATION:  I hereby authorize the Hilltop Medical Clinic to furnish my insurance company(ies), and/or their Attorney or collection agency, with and all information which said parties may request or be provided with, concerning my office visits here.   

WAIVER OF CONFIDENTIALITY:  If this account is submitted to an attorney or collection agency, goes to court or is reported to a credit reporting agency, the fact that you received treatment here may become a matter of public record.    

ASSIGNMENT OF BENEFITS:  I hereby assign Hilltop Medical all money to which I am entitled for medical and/or surgical expense related to the services reported herein, but not to exceed my indebtedness to Hilltop Medical Clinic.  It is understood that any money received from the insurance company(ies) over and above my debt will be refunded to me, or back to my insurance company, when my bill is paid if full.  I understand that I am financially responsible to Hilltop Medical Clinic for charges not covered by this assignment. 

EFFECTIVE DATE:  Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

 

SIGNATURE -TO BE DONE AT THE FRONT COUNTER ELECTRONICALLY