I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to Senior Care EMS for any services provided to me by Senior Care now or in the future. I understand that I am financially responsible for the services provided to me by Senior Care 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 Senior Care EMS amy 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 Senior Care EMS. I authorize Senior Care EMS to to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to Senior Care EMS and its billing agents, and/or the Centers for Medicare andMedicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by Senior Care EMS, now or in the future. A copy of this form is as valid as an original.

Privacy Practices Acknowledgment: by signing below, I acknowledge that I have received Senior Care EMS Notice of Privacy Practices.

SIGNATURE SECTION: One of the following three sections MUST be completed.

SECTION I - PATIENT SIGNATURE

The patient must sign here unless the patient is physically or mentally incapable of signing:

Patient Signature or Mark:

If the patient signs with an "X" or other mark, it is recommended that someone sign below as a witness:

Witness Signature:

Witness Printed Name:

If patient is physically or mentally incapable of signing, Section II must be completed.

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE

Complete this section only if patient is physically or mentally incapable of signing.

Reason the patient is physically or mentally incapable of signing:

Authorized representatives include only the following individuals (check one):

Patient's Legal Guardian Patient's Health Care Power of Attorney
Relative or other person who receives government benefits on behalf of patient
Relative or other person who arranges treatment or handles the patient's affairs
Representative of an agency or institution that furnished care, services or assistance to the patient.

I am signing on behalf of the patient. I recognize that signing on behalf of the patient is not an acceptance of financial responsibility for the services rendered.

Representative's Signature:

Representatives Printed Name:

SECTION III - EMERGENCIES ONLY - AMBULANCE CREW AND FACILITY REPRESENTATIVE SIGNATURES

Complete this section only for emergency ambulance transports, if patient was physically or mentally incapable of signing, and no authorized representative (as listed in Section II) was available or willing to sign on behalf of the patient at the time of service.

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 named above 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.

Reason patient incapable of signing: Name and Location of Receiving Facility:
Time at Receiving Facility:

Signature of Crewmember:

Printed Name of Crewmember:

B. Receiving Facility Representative Signature

The above-named patient was received by this facility at the date and time indicated above.

Signature of Receiving Facility Representative:

Printed Name of Receiving Facility Representative:

C. Secondary Documentation

If no facility representative signature is obtained, the ambulance crew should attempt to obtain one or more of the following forms of documentation from the receiving facility that indicates that the patient was transported to that facility by ambulance on the date and time indicated above. The release of this information by the hospital to the ambulance service is expressly permitted by Section 164.506(c) of HIPAA.

Patient Care Report (signed by representative of facility) Facility Face Sheet/Admissions Record
Patient Medical Record Hospital Log or Other Similar Facility Record