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By signing below, I (the patient) understand that I will be held financially responsible for all charges resulting from services provided. I authorize direct payment of medical benefits from my insurance company to Pioneer Physicians Network, Inc. In addition, I authorize release of any medical information necessary for reprocessing of these claims for payment including, but not limited to, facsimile transmission of information.
I consent to the use of my medical information necessary for transmission of prescriptions to the pharmacy and as needed for the coordination of formulary and/or benefits eligibility with my insurance provider. I consent to the query of my external prescription history as necessary to manage my healthcare and related services.
In accordance with the notices of privacy practices, I authorize the use and disclosure of any medical information with a third party to coordinate or manage my healthcare or any related services.
I have read and understand the Pioneer Physicians Network Financial and Annual Patient Consent for Release of Information and Medical Claims Processing Policy. I agree to assign insurance benefits to Pioneer Physicians Network whenever necessary.