Privacy Notice

Privacy Practices Acknowledgment: by signing below, the signer acknowledges that Mid-County EMS 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* I authorize the submission of a claim for payment to Medicare, Medicaid, or any other payor for any services provided to me by Mid-County EMS 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 Mid-County EMS, 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 Mid-County EMS 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 Mid-County EMS. I authorize Mid-County EMS to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or other relevant documentation about me to release such information to Mid-County EMS and its billing agents, the Centers for Medicare and Medicaid Services, and/or any other payors 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 Mid-County EMS, now, in the past, or in the future