Cardiology Associates of Atlanta, PC Patient Information Form

_________________________ Copay Amount _______________ Type of Plan: HMO PPO POS EPO COMMERCIAL INDEMNITY MEDICARE MEDICAID (circle one) Insured 9s Name _______________________ Insured 9s SS# ___________________ Insured 9s DOB ____________ Guarantee of Account : I understand that I am fully responsible for all charges made to my account. I hereby authorize CARDIOLOGY ASSOCIATES OF ATLANTA, PC, to release any medical information necessary to process claims or any information requested from my records.<br><br> I hereby authorize payment of medical benefits to CARDIOLOGY ASSOCIATES OF ATLANTA, PC, for services rendered. Medicare Assignment : I am giving CARDIOLOGY ASSOCIATES OF ATLANTA, PC, permission to ask for Medicare payments for my medical care. I understand that Medicare needs information about me and my medical condition in order to make a decision about these payments.<br><br> I give permission for that information to go to Medicare and companies that handle Medicare payment requests. I understand that the Centers for Medicare and Medicaid Services (CMS) is the government Medicare Agency. I request that payment of authorized Medicare benefits by made to or in my behalf to CARDIOLOGY ASSOCIATES OF ATLANTA, PC, for services furnished me by the CARDIOLOGY ASSOCIATES OF ATLANTA, PC provider.<br><br> I authorize any holder of medical or other information about me to be released to CMS and its agents to determine benefits for services rendered or related services. SIGNATURE: _____________________________________________________ DATE _____________________

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