Patient Information

I hereby assign to and authorize payment of all benefits payable under the terms of my health insurance policy (policies) to ·Birmingham Pulmonary Group, P.C. I request payment of authorized Medicare benefits be made on my behalf to Dr. Strickland, Dr. Heidecker, Dr. Daniel, Dr. Gamer, Ashleigh Reimann, Michelle Price or Jaime Cannon for any services furnished by that physician. I authorize the release of any medical information needed to process claims. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits. In carrying out my treatment, it might be necessary to FAX my records to the hospital or to another doctors group. By signing below I am authorizing the release of my records in this fashion. It is the patient's responsibility to notify this office of any insurance changes. i I understand that I am responsible for any and all charges incurred by me and that I agree to pay any collection costs incurred/ including a reasonable attorneys fee.