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Get and Sign Authorization for Release of Information and Payment 2018

Get and Sign Authorization for Release of Information and Payment 2018

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Unauthorized disclosure of these records. University of Iowa Hospitals and Clinics UIHC Hosp. Patient Financial Services 200 Hawkins Dr. Iowa City IA 52242 FAX 319-356-8939 A A Authorization to Bill Insurance Release of Information and Payment Request Patient Name Birth Date A. The unauthorized disclosure of this information is unlawful and civil damages and criminal penalties may be applicable to the unauthorized disclosure of said information pursuant to the Iowa code. I agree to pay for...
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