Common Contracts
1 similar null contracts
Patient InformationMay 9th, 2008
I/We hereby authorize Richmond Vein Center to furnish all information regarding my medical history, diagnosis and treatment of myself or my child to an insurance company regarding my claims for benefits. If however, said insurer fails to meet this obligation in whole or in part, or if I am non-insured, agree to be responsible for the fee and cost involved in the treatment of the above named patient. I/We authorize payment of medical benefits to the Richmond Vein Center and further understand that should my account have to be referred to an attorney for collection that I am responsible for all fees and costs incurred therein. I/We hereby authorize Richmond Vein Center to act on my behalf in accessing hospital records when and if needed.
