HCAA Refusal Form

HCAARefusal/AMA Signature Form
 INSURANCE BILLING AUTHORIZATION FORM FOR EMT/PARAMEDIC ON SCENE ASSESMENT AND/OR AMBULANCE
SERVICE
This form authorizes HCAA EMS to bill Medicare and/or any other insurance company or government health benefit program for the ambulance and/or
paramedic/EMT services provided to you or your dependents. If this form is not signed, you are responsible for paying the entire balance of your account “I request
that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to HCAA for any services provided to me by HCAA now or in
the future. I understand that I am financially responsible for the services provided to me by HCAA, regardless of my insurance coverage, and in some cases, may be
responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to HCAA any payments that I receive directly from
insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to HCAA. I authorize HCAA to appeal
payment denials or other adverse decisions on my behalf without further authorization.”
“I authorize and direct any holder of medical information or documentation about me to release such information to HCAA and its billing agents, and/or the
Centers for Medicare and Medicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other
benefits payable for any services provided to me by HCAA, now or in the future. A copy of this form is as valid as an original.”
□ PATIENT CONSENT FOR RELEASE NON- EMT/PARAMEDIC TRANSPORT NON-INJURY OR MINOR INJURY
I understand that a preliminary field evaluation has not revealed any condition sufficiently serious to require transportation to the hospital by EMTs/Paramedics. I
agree with this assessment. I also understand that, while I still have the option of being transported to the hospital by EMTs/Paramedics, I prefer to make my own
transportation arrangements for further evaluation. If my present condition worsens, I have been advised to seek prompt medical evaluation, which may include
requesting EMTs/Paramedics respond again by dialing 911. This is to certify that I release HCAA EMS and its employees and agents from any liability for any claim
arising from, or associated with, my injuries or medical condition.
□ PRE-HOSPITAL PATIENT RELEASE AGAINST MEDICAL ADVICE (AMA) Refusal of Medical Treatment and Transportation
This is to certify that I release HCAA EMS and its employees and agents, the hospital or facility and its staff, and any treating physicians, from liability for any claim
arising from, or associated with, my injuries or medical condition; and I refuse further treatment and medical transportation to the hospital, even though I am informed
and I am aware that my injuries or medical condition may be serious and may require further treatment.
□ TRANSPORT DESTINATION AGAINST MEDICAL ADVICE (DESTINATION AMA) Refusal of Transport to Nearest Facility
This is to certify that I release HCAA EMS and its employees and agents, the hospital or facility and its staff, and any treating physicians, from liability for any claim
arising from, or associated with, my injuries or medical condition; and I refuse transport to the closest hospital that is capable of treatment of my illness or injury. I also
understand that HCAA is under the medical direction of Kootenai County physicians and will be transporting out of their medical direction. I am
informed and I am aware that my injuries or medical condition may be serious and may require immediate treatment. I acknowledge that I have read and understand
the terms of this release, and I have signed it voluntarily. I agree that this release shall be binding on my relatives, heirs, legal representatives and assigns.
I acknowledge that I have read and understand the terms of this release, and I have signed it voluntarily. I agree that this release shall
be binding on my relatives, heirs, legal representatives and assigns. I understand that I may be billed for services, procedures and/or
assessments that were provided to me on scene.
X        _____________________________________________    ______________
Patient Signature                  Date
______________________________________________________________________________________________________________________________
Complete this section only if the patient is physically or mentally incapable of signing.
Reason the patient is physically or mentally incapable of signing:
Authorized representatives include only the following individuals (check one):
 Patient’s Legal Guardian
 Patient is a minor – Parent to sign below
 Relative or other person who receives government benefits on behalf of patient
 Patient’s Health Care Power of Attorney
 Relative or other person who arranges treatment or handles the patient’s affairs
I am signing on behalf of the patient and release HCAA of liability
X        ________________________________________  __________           ______
Representative Signature            Date     Printed Name of Representative
_____________
Representative’s Address
HARRISON COMMUNITY AMBULANCE ASSOCIATION