The following statement is our Hippa / Billing statement:

I understand that I am financially responsible for the services provided to me by TEMS regardless of insurance coverage. I request that payment of authorized Medicare, Medicaid, or other insurance benefits be made on my behalf to TEMS for any services provided to me by TEMS. I authorize and direct any holder of medical information or documentation about me to release to the Centers of Medicare and Medicaid Services and its carriers and agents, as well as to TEMS and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by TEMS, now or in the future. I agree to immediately remit to TEMS any payments that I receive directly from any source for the services provided to me and I assign all rights to such payments to TEMS.