Assignment of Benefits and Privacy Acknowledgement Form
Patient Name: _____________________________________________ Transport Date: _____________ ______
Privacy Practices Acknowledgment: by signing below, the signer acknowledges that GVFD/EMS Service provided a copy of its Notice of Privacy Practices to the
patient or other party with instructions to provide the Notice to the patient.
*A copy of this form is valid as an original*
This is a sample only and does not constitute legal advice. User bears all responsibility for compliance with all applicable laws and regulations.
This is a sample o
On the line below, explain the circumstances that make it impractical for the patient to sign:
__________________________________________________________________________________________________________________________
I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services
provided to the patient by GVFD/EMS Service now or in the past, (or in the future, where permitted). By signing below, I acknowledge that
I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:
Patient’s legal guardian
Relative or other person who receives social security or other governmental benefits on behalf of the patient
Relative or other person who arranges for the patient’s treatment or exercises other responsibility for the patient’s affairs
furnished other care, services, or assistance to the patient
Representative of an agency or institution that did not furnish the services for which payment is claimed (i.e., ambulance services) but
X ______ ________ _______ __________________________________________________________________________
Representative Signature Date Printed Name and Address of Representative
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by GVFD/EMS Service now, in
the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services
and supplies provided to me by GVFD/EMS Service, regardless of my insurance coverage, and in some cases, may be responsible for an
amount in addition to that which was paid by my insurance. I agree to immediately remit to GVFD/EMS Service any payments that I receive
directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to GVFD/EMS
Service. I authorize GVFD/EMS Service to appeal payment denials or other adverse decisions on my behalf without further authorization. I
authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to GVFD/EMS
Service and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective
agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by GVFD/EMS
Service, now, in the past, or in the future. I also authorize GVFD/EMS Service to obtain medical, insurance, billing and other relevant
information about me from any party, database or other source that maintains such information.
If the patient signs with an “X” or other mark, a witness should sign below.
X ______________ ______________ X_____________________________________ __________________________
Patient Signature or Mark Date Witness Signature Date
___________________________________________________________
Witness Address
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)
My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the
authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. I am signing on behalf
of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient
by GVFD/EMS Service. My signature is not an acceptance of financial responsibility for the services rendered.
On the line below, explain the circumstances that make it impractical for the patient to sign:
______________________________________________________________________________________________________________________
Name and Location of Receiving Facility: _______________________________________________________________________________________
Time at Receiving Facility: ____________________________
X _______ _______ __ ________ _____ __
Signature of Crewmember Date Printed Name and Title of Crewmember
B. Receiving Facility Representative Signature
The patient named on this form was received by this facility on the date and at the time indicated above. I am signing on behalf of the
patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by
GVFD/EMS Service. My signature is not an acceptance of financial responsibility for the services rendered.
X ____ ____ ___ ______ __
Signature of Receiving Facility Representative Date Printed Name and Title of Receiving Facility Representative
SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE
Complete this section only if the patient is physically or mentally incapable of signing.
SECTION I - PATIENT SIGNATURE
The patient must sign here unless the patient is physically or mentally incapable of signing.
NOTE: if the patient is a minor, the parent or legal guardian should sign in this section.
SECTION III - AMBULANCE CREW AND RECEIVING FACILITY SIGNATURES
Complete this section only if: (1) the patient was physically or mentally incapable of signing, and
(2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
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