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Please complete the form below.

Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mulvane Ambulance Service (MES) provided a copy of its Notice of Privacy Practices to the patient or other party with instructions to provide the Notice to the patient. *A copy of this form is valid as an original*

* Denotes a required field

Section I - Patient Signature

The patient must sign here unless the patient is physically or mentally incapable of signing. Note: if the patient is a minor, the parent or legal guardian should sign in this section.
I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by MES now, in the past, or in the future, until such time as I revoke this authorization in writing. I understand that I am financially responsible for the services and supplies provided to me by MES, regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to MES any payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to MES. I authorize MES to appeal payment denials or other adverse decisions on my behalf. I authorize and direct any holder of medical, insurance, billing or other relevant information about me to release such information to MES and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payers or insurers, and their respective agents or contractors, as may be necessary to determine these or other benefits payable for any services provided to me by MES, now, in the past, or in the future. I also authorize MES to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information. If the patient signs with an “X” or other mark, a witness should sign below.
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Date*
 Date

Section II - Authorized Representative Signature

Complete this section only if the patient is physically or mentally incapable of signing.
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I am signing on behalf of the patient to authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by MES now or in the past or in the future. By signing below, I acknowledge that I am one of the authorized signers listed below. My signature is not an acceptance of financial responsibility for the services rendered.
Authorized representatives include only the following individuals:*
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Section III - Ambulance Crew and Receiving Facility Signatures

Complete this section only if: (1) the patient was physically or mentally incapable of signing, and (2) no authorized representative (Section II) was available or willing to sign on behalf of the patient at the time of service.
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Time*
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A signature below authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided to the patient by MES.
A. Ambulance Crew Member Statement (must be completed by crew member at time of transport) My signature below indicates that, at the time of service, the patient was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient’s behalf. My signature is not an acceptance of financial responsibility for the services rendered.
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B. Receiving Facility Representative Signature The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient. My signature is not an acceptance of financial responsibility for the services rendered.
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Please click submit when finished.