Responsibility, Consent & Assignment of Benefits Form

First Name
Last Name
Street Address
Address Line 2
State / Province / Region
Postal / Zip Code

Release of Information

I authorize Valley Surgery Center to release pertinent information and/or copies of medical records for treatment, payment or health care operations purposes. I understand such information may include Human Immunodeficiency Virus (HIV), AIDS Related Complex (ARC), Acquired Immunodeficiency Syndrome (AIDS), hepatitis, substances abuse, psychiatric/psychological services records, and social work records, if any to the extent that the release of such records is permitted under federal and state law. See Notices of Privacy Practices for further information.


I release valley Surgery Center from responsibility for all personal articles which I have with me during the time I am a patient at the Facility. I understand that the Facility is not responsible for clothing, eyeglasses, dentures, jewelry, money or other personal articles of value kept in my possession while a patient in the surgery center.


I assign and authorize payment from my insurance company directly to Valley Surgery Center for any and all services rendered. I agree to pay, at the time of discharge or on an interim basis (agreed upon by the Facility), all charges not covered by my insurance company. In understand that it is my primary responsibility to pay the Facility all charges for services rendered irrespective of any disputes or disagreement between myself and insurance companies.

Relationship Between Facility and Physicians

I acknowledge that medical/surgical services at Valley Surgery Center are provided by its employees as well as physicians on its Medical Staff and other health care providers, many of whom are not employees of Valley Surgery Center but are licensed independent practitioners who have been granted the privilege of using the Center's facilities for the needs of their patients. I understand that my attending physicians (or his/her deisgnee) will be responsible for my care at all times.

Medicare/Medicaid Payment

I certify that the information given by me in applying for, or assigning, payment under Medicare or Medicaid is correct. I request payment of authorized Medicare/Medicaid benefits be paid to Valley Surgery Center on my behalf for services furnished to me. I authorize Valley Surgery Center to release any information about me that is necessary to act on this request for payment.