I assign payment of all insurance or other benefits, under which I am entitled to coverage, to ChristianaCare, its healthcare contractors and related physician groups, as applicable, for healthcare services provided to me during my patient care visit. I specifically provide my consent effective with the date of my initial treatment and/or admission by ChristianaCare as the protective filing date to apply for Medicaid entitlement benefits to cover my medical treatment, with respect to my application for Medicaid coverage, in the event I need to apply.
Where Medicare benefits apply, I confirm the information provided by me in applying for payment under Title XVIII of the Social Security Act is correct. I request payment of authorized Medicare benefits to ChristianaCare and its contracted services and physician groups for any services I receive. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine the benefits for related services.