Authorization and Assignment
I request that payment of authorized Medicare, Medicaid, Commercial Carrier, Workman's Compensation, or VA benefits on my behalf be made to Northwest Arkansas EMG Clinic for any services provided to me.
I authorize Miles Johnson, M.D. to release to the Health Care Administration and its agents any information needed to determine benefits payable for related services.
I understand that I am responsible for any deductible,
co-payments or services not covered by my insurance carrier.
I authorize the physician to release any information required by my insurance company and/or another physician.
I acknowledge the offer of Notice of Privacy Practices. I give permission to release my medical records to myself at my request.
I authorize treatment provided by Miles Johnson, M.D.
Please sign electronically below.