I understand that I am
responsible for charges not covered or reimbursed by the
above agents. I agree, in the event of non-payment, to
assume the costs of interest, collection and legal action
(if required).
I authorize my insurance
carrier to release information regarding my coverage to
Dallas ID Associates ( DIDA). I also authorize agents of
any hospital, treatment center or previous physicians to
furnish DIDA copies of any records of my medical history,
services or treatments. I also authorize the release of
any medical information and/or reports related to my treatment
to any federal, state or accreditation agency, or any physician
or insurance carrier as needed. I also agree to a review
of my records for purposes of internal audits, research
and quality assurance reviews within DIDA.
My right to payment for
all pharmaceuticals, procedures, tests, medical equipment
rentals, supplies and nursing/physician services, including
major medical benefits, are hereby assigned to DIDA. This
assignment covers any and all benefits under Medicare,
other government-sponsored programs, private insurance
and any other health plans. I acknowledge this document
as a legally binding assignment to collect my benefits
as payment of claims for services. In the event my insurance
carrier does not accept Assignment of Benefits, or if payments
are made directly to my representative or me, I will endorse
such payments to DIDA.
I understand that my
patient information arising out of my medical treatment
by my physician and this medical practice (without identifying
me or any other patient by name or address, unless otherwise
permitted by law) may also be shared with interested third
parties. These third parties include: (a) managed care
companies, insurance companies and other payors; (b) companies
that produce chemotherapy and other drugs and clinical
research companies; (c) governmental bodies (such as the
Food and Drug Administration, the National Cancer Institute
and the Health Care Financing Administration); (d) federally
funded registries (which in the case of patients receiving
stem cell transplant services my include the sharing of
patient-identifying information such as my name and address)
and universities; (e) representatives and agents of my
health benefit plan; (f) persons conducting quality or
peer review or patient satisfaction surveys; and (g) other
clinical and non-clinical parties that have a contractual
relationship with DIDA.
This agreement/consent
will remain in effect unless revoked by me in writing
