Southern California
180 Otay Lakes Rd, Ste 110, Bonita, CA 91902
Advanced Heart Care, Inc.
Northern California
2510 Airpark Drive, Ste 205, Redding, CA 96001
180 Otay Lakes Rd, Ste 110,
Bonita, CA 91902
2510 Airpark Drive, Ste 205,
Redding, CA 96001
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