Release of Information: I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services, its intermediaries, or to any third-party payor, as required, any information needed for this or a related health claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts the assignment.
I also authorize the release of medical information to my physician(s) and other health care providers to assist in my treatment, auditors authorized by Pinnacle HomeCare, LLC (for the purpose of certification, licensure, or accreditation), and to the following individuals who may be involved in assisting with my affairs: