The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance.
ASSIGNMENT OF INSURANCE BENEFITS:
I authorize payment of medical benefits, otherwise payable to me, to OUTCOMES DETOX & RECOVERY for all the services they provide. I understand that I am financially responsible to the Medical Associates of Brownsville for charges not covered by this assignment. I authorize OUTCOMES DETOX & RECOVERY to release to my insurance company any medical information for processing of a claim. I authorize OUTCOMES DETOX & RECOVERY to obtain information pertaining to my insurance coverage and benefits from the carrier of same. I permit a copy of this authorization to be used in place of the original.
AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:
I certify that I have received and read a copy of OUTCOMES DETOX & RECOVERY'S Patient Information Privacy Policy. I hereby authorize OUTCOMES DETOX & RECOVERY to release any of my, or my dependent's, medical or incidental non-public personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits.
CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY:
I authorize Medical Associates of Brownsville to view my external prescription history via the RxHub service. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.
CONSENT TO TREATMENT:
I hereby consent to evaluation, testing, and treatment as directed by my physician or his/her designee.
MY SIGNATURE CERTIFIES THAT I HAVE READ AND UNDERSTOOD THE SCOPE OF MY CONSENT AND THAT I AUTHORIZE THE ACCESS
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