LIFETIME ASSIGNMENT OF BENEFITS

I understand that I am financially responsible for the services provided to me by __________ Ambulance regardless of insurance coverage.  I request that payment of authorized Medicare or other insurance benefits be made on my behalf to _________ Ambulance or its billing agent (911 Billing Services) for any services provided to me by __________ Ambulance.  I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) and its carriers and agents, as well as to _________ Ambulance and its billing agents, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by __________ Ambulance, now or in the future.  I agree to immediately remit to _______________ Ambulance any payments that I receive directly from any source for the services provided to me.  A copy of this form is as valid as the original.

I further acknowledge that I have received [ ] or have refused [ ] a copy of _____________ Ambulance’ Notice of Privacy Practices.  A copy of this form is as valid as the original.

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Signature of Policyholder/Insured/Responsibly Party                                    Date

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Witnessed by                                                                                                                                      ________________________________________