By Clicking Submit: I authorize the submission of a claim to Medicare, Medicaid, or any other payer for any services provided to me by LAA 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 LAA, 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, including, where applicable, any fees incurred should my claim be submitted to a collection agency or attorney. I agree to immediately remit to LAA 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 LAA. I authorize LAA to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information, insurance, billing or other relevant information about me to release such information to LAA 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 LAA, now, in the past, or in the future. I also authorize LAA to obtain medical, insurance, billing and other relevant information about me from any party, database or other source that maintains such information. My signature certifies that I received a service or item on the date listed below. I understand that payment will be made from Federal and State funds and that any false claims, statements, or documents, or concealment of material information may be prosecuted under applicable Federal and State laws.
