All Patients Please Sign and Date Below Consent for Treatment; Authorization for Release of Information and Assignment of Insurance Benefit I hereby consent to and authorize all treatment considered necessary and advisable by the physician or office staff including, but not limited to, medical treatment, examinations, diagnostic procedures, vaccinations, and immunizations during the course of patient care.
I authorize payment directly to Riverside Cardiology Associates and hereby agree that I am financially responsible for any services rendered. I authorize the release of any information needed to the Centers for Medicare & Medicaid Services (CMS) and its agents to determine these benefits payable. I certify that information that I have provided above is true and correct to the best of my knowledge.
Acknowledgement of Receipt of Privacy Notice I have been informed of the notice of privacy policies detailing how my information may be used and disclosed as permitted, additionally, this copy is available upon request.
Please don't include medical details in this form. For urgent questions, call 951-686-3600
