This form authorizes the City of Escondido to bill Medicare and/or any other insurance company or government health benefit program for the ambulance and/or paramedic services provided to you or your dependents. Please fill out and return this form to us as soon as possible, since your insurance cannot be billed until this form is returned. If this form is not returned, you are responsible for paying the entire balance of your account.
“I request that payment of authorized Medicare and/or other insurance or government health benefits be made either to me or on my behalf to the City of Escondido for any services furnished me by the City of Escondido, their agents and employees. I authorize any holder of medical information about me to release to the City of Escondido, the Health Care Financing Administration (Medicare) and/or any other insurance company, including their agents and employees, any information or documentation needed to determine these benefits or the benefits payable for related services.”
“I understand my signature requests that payment be made and authorizes release of medical information necessary to secure payment for the claim. If I have supplemental health insurance coverage, my signature authorizes releasing the medical information to the supplemental insurance company, their agents and employees. This signature authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization is to be considered as valid as an original.”