I authorize any holder of medical or other information about me to release to Social Security Administration and Health Care Financing Administration or the intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other insurance company claim.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.  If item 9 of the HCFA 1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown.  In Medicare/Other insurance company assigned cases, the physicians/supplier accept the charge determination of the Medicare/Other insurance company as the full charge (excluding non-contracted insurance), and the patient is only responsible for the deductible, coinsurance, co-payment or non-covered services.