Union Regional Medical Center

Union Regional Medical Center Carolinas HealthCare System Franklin Street Ambulatory Clinic PO Box 217 Monroe, N. C. 28111 704-289-9461 OUTPATIENT REGISTRATION

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Social Security, Medicare, Medicaid: I certify that the information given by me in applying for payment under Title XVII and of Title XIX of the Social Security Act is correct. I authorize, if applicable, any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization that submits a claim to Medicare/Medicaid for payment for me. Consent for treatment: I am presenting myself for diagnosis and treatment at Franklin Street Ambulatory Clinic and consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions by authorized members of the hospital staff or their designers, and may in their professional judgement, be necessary. I acknowledge that no guarantee has been made to me as to the effect of such examination or treatment of my condition. Authorization for treatment, assignment of benefits, release of medical information: I hereby grant permission to the attending physician to perform such medical and surgical procedures at they deem necessary, and authorize any insurance company or companies with whom the attending physician process claims on my behalf to remit payment directly to the attending physician proceeds due, including major medical, otherwise payable to me and authorize the release of any medical information required for processing such insurance claims or Worker’s Compensation Claim. North Carolina Department of Human Resources Inspection: I understand that I may object in writing to the inspection of my records by the North Carolina Department of Human Resources.

Signed______Date______URMC – 1401 (11/4/04)