Last Modified: March 13, 2019
I authorize Firefly Medical Group to submit claims on my behalf to my insurance payers, which may include Medicare, Medicaid, and other commercial or governmental payers. I assign any payment and/or benefit from these payers for these services to Firefly Medical Group. I further consent to the release of any health information necessary for the adjudication and payment of claims or any authorizations for services or procedures rendered or to be rendered. I understand that amounts owed for deductibles, co-insurance, co-payments, and non-covered services are my financial responsibility. If any balances become delinquent and are referred for further collection activity, I may become liable for any cost of collection including collection fees, court fees, and legal fees.