Primary Insurance Information

Secondary Insurance (if applicable):

Authorization and Agreement – I request that benefits be paid by my insurer or health plan (including Medicare) directly to Cancer Center of Sarasota. I understand that I will be responsible for any outstanding or unpaid balance on my bill. I certify that the information I have reported with regard to my insurance is correct. I authorized the release of medical or other necessary information for this or any related claim to my insurance carrier, or in the case of Medicare Part B benefits, to the Social Security Administration and Health Care Financing Administration. I permit a copy of this authorization to be used in lace of the original. I authorize the release of my medical records as requested orally or in written form by my physician or me. I have read and consent to the authorization and assignment stated above.

Financial Agreement: I understand that I am responsible for the payment of any sums not covered by my health insurance. I further understand that if I don’t carry health insurance, I am responsible for payment of the full amount. I understand that I am responsible for the payment of this account and hereby assume and guarantee payment of expenses incurred by myself or my descendents. Should legal action be required to secure payment of this account I agree to a reasonable collection expense, all court costs and reasonable attorney’s fees incurred thereby.

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