Authorization for Release of Information

Note: Fields marked with an * indicates required field

Form 2 of 11

I authorize Marwood Nursing & Rehab to release information to process third-party payment claims.

I certify that the information given by me in applying for payment under Medicare, Medicaid, Blue Cross, or Private Insurance Company, as may be considered necessary to secure payment of claims, is correct.

I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediaries or carriers, or the Michigan Department of Human Services, or Marwood Nursing & Rehab, any information needed for a related Medicare or Medicaid claim. I request that payment or authorized benefits be made in my behalf. This authorization will remain valid until revoked in writing by the undersigned.

I assign payment for the unpaid charges furnished by Marwood Nursing & Rehab, for which Marwood Nursing & Rehab is authorized to bill.

I understand that I am responsible, and agree to pay in full, and / or remaining balances including patient pay amounts, deductibles, and coinsurances.

If signing on the Residents behalf, please provide the Resident's name in the Resident section.

By submitting this Authorization, please be aware that an electronic signature is as legally binding as a handwritten signature.