Southern California
Advanced Heart Care, Inc.
Northern California
2345 E. 8th St, Suite 111
National City, CA 91950
11939 Rancho Bernardo Road
Rancho Bernardo, CA 92128
2510 Airpark Dr # 205
Redding, CA 96001
EMERGENCY CONTACT
Please present your insurance card(s) with this completed form
ASSIGNMENT OF BENEFITS - CONSENT FOR TREATMENT - RELEASE OF INFORMATION
I hereby assign all medical and/or surgical benefits, including Medicare, private insurance, and/or any other plan to Advanced Heart Care, Inc. This assignment will remain in effect for one year from date signed. A scan and/or photocopy of this assignment will be considered as valid as an original. I understand that I am financially respoinsible fro all charges whether or not paid by insurance. I hereby authorize said assignee to release information necessary to secure payment. I hereby authorize Advanced Heart Care, Inc. to perform any medical treatment necessary.
As a courtesy to other patients, we require 24 hours advance notice prior to any cancellation or rescheduling.
(619) 585-0476
(530) 433-5427
Fax: (530) 236-8872