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Patient Name: ___________________________________Account: ____________________ RELEASE OF INFORMATION & ASSIGNMENT OF BENEFITS I authorize Wise Regional Health System to release to Government Agencies, Insurance Carriers, or others who are financially liable for my hospitalization and medical care all information needed to substantiate payment for such services. Information may be released via electronic transmission. I assign payment directly to Wise Regional Health System and medical benefits to which I may be entitled to cover the cost of care and treatment rendered to myself or my dependent. Wise Regional Health System is permitted to allow payers to examine and make copies of the patient’s record as required for payment. I agree to be financially responsible for the hospital charges for the patient named above that are not paid by third-party benefits. For maternity patients this includes any charges for a newborn that are not covered by third-party benefits. X___________________________________________ NO INFORMATION ___ I do not authorize release of any information regarding my admission or treatment. I wish to be a “No Information” patient, and I realize that flowers, telephone calls and visitors will be refused on my behalf. PUBLIC DIRECTORY INFORMATION ___ I authorize public disclosure of “directory” information including my name, city of residence, and my room number. PATIENT’S RIGHTS POLICY ___ I have received a copy of the Wise Regional Health System Patient’s Rights Policy. ACKNOWLEDGMENT OF RECEIPT ___ My Signature only acknowledges my receipt of the Medicare Conditions of participation from Wise Regional Health System on today’s date and does not waive any of my rights to request a review or make me liable for a any payment. X____________________________________________________
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