I request that payment of authorized Medicare benefits and/ or Medicare Supplement benefits be made either to me or on behalf to Mid Illinois Medical Care Associates, L.L.C for any services furnished to me by the physician(s) and/or supplier. I authorize any holder of medical information about me to release to the centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) and its agent or to the above Medicare Supplement Insurer, any information needed to determine these benefits or the benefits payable for related services. I understand that I am responsible for any non covered- services.
If the patient fails to make any payment due, Mid Illinois Medical Care Associates, LLC may at any time declare the entire unpaid, balance of the account to be immediately due and payable from the patient. The patient also agrees and promise to pay all cost of collection, including the contingency fees of a collection agency and reasonable attorney's fees incurred by Mid Illinois Medical Care Associates, LLC for the enforcement of this agreement (or contract) for payment following default. the patient acknowledges that he/she shall be liable for contingency collection fees and attorneys fees in an amount equal to 50% of the original balance owned and those fees shall be added to the amount of the original bill for collection purposes.
By providing a proxy e mail address, you are permitting the proxy to have access to the information in your patient portal. All of your medical information that is available in your patient portal will be available in your patient portal will be available to your proxy by signing below. Patient Portal may include information about mental health treatment, sexually transmitted diseases, HIV/AID's, genetic testing, and incidental records related to alcohol and substance abuse. This authorization does not allow the release of any other content in your medical record other than what is accessible on the Patient Portal. If any other documentation is required. the patient and/or legal guardian must obtain proper authorization. You may revoke this authorization at any time by submitting a written request to revoke proxy access to your physician's office.