CENTRAL ILLINOIS INSTITUTE OF BALANCE
211 Landmark Drive, Ste E3
Normal, Illinois61761
Phone: 309-663-4900, Fax: 309-663-4197,
CONSENT TO TREAT: I request and give consent to Central Illinois Institute of Balance to provide and perform tests, procedures and other services, and supplies as considered necessary or beneficial for my health and well being. I acknowledge that no representation; warranties or guarantees as to the results or cures have been made to me.
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Initial
RELEASE OF MEDICAL INFORMATION AND AUTHORIZATION TO PAY BENEFITS:
I authorize Central Illinois Institute of Balance to release information from my medical record to my insurance carriers or government agencies for processing of medical claims for medical benefits. I request that my insurance company (or companies) honor my assignment or insurance benefits applicable to the services and pay all of the insurance benefits directly to Central Illinois Institute of Balance on my behalf.
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Initial
MEDICARE CERTIFICATION: I certify that the information given by me in applying for payment under the title XVIII of the Social Security Act is correct. I authorize Central Illinois Institute of Balance to release information from my medical record to the Social Security Administration and/or the Medicare program or its intermediaries or carriers for the processing of claims for medical benefits. I request that payment of authorized benefits be made directly to Central Illinois Institute of Balance, on my behalf.
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Initial
FINANCIAL AGREEMENT: I understand that all accounts are the responsibility of the patient and/or the patient’s responsible party, guarantor or parent(s). I acknowledge that the information provided by me is correct and that it has been furnished to this office and with full knowledge that I am liable for all services rendered and that I am contractually bound to pay for said services. As a courtesy to me, Central Illinois Institute of Balance will assist me in obtaining insurance benefits by filing claim for services and not products when I have assigned those to Central Illinois Institute of Balance. I understand that it is my responsibility to respond promptly to any requests for the information from my insurance carrier or Central Illinois Institute of Balance. I promise to pay any collection costs and reasonable attorney fees incurred to effect collection of the account.
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Initial
MINOR PATIENT:I certify that I am the legal guardian of the minor named below and I authorize Central Illinois Institute of Balance to perform procedures required for evaluation and treatment.
Name of Minor:____________
Initial
______Date ______/______/______
Signature of Patient/Parent/Guardian
PLEASE BRING PHOTO ID TO APPOINTMENT