Forms

Authorization and Assignment Form - Form which must be completed in order for Springfield Clinic to submit charges to insurance carriers on the patient's behalf. (en Español)

Authorization for Release of Medical Information – The authorization for release of information is needed for hard copy medical records.

Notice for Revocation Authorization Form - Filled out when a patient chooses to revoke a previously completed authorization.

Special Billing Form - Filled out by the patient when the claim for services they are receiving that day are not to be billed to the patient’s regular health insurance (work injury, automobile injury, personal liability injury). A signed copy of this form is to be given to the receptionist at each doctor’s visit as well as to each provider of ancillary services such as laboratory, x-ray or physical therapy.

Statement of Billing Agreement -Filled out by the custodial parent when a minor child needs to be moved to the non-custodial parent’s account.  Both parents are required to sign this form.

Statement of Extended Family Billing Agreement - Form to be completed when the patient, who is no longer a minor, chooses to remain on their parent's account.

Verbal Authorization Form - This authorization must be signed by the patient in order for Springfield Clinic to speak with specified individuals about the patient's account or medical information. (en Español)