HIPAA Authorization with Instructions

HIPAA Authorization for Release of Information

MBFS cannot generally release information without the approval of the patient or guardian without an appropriate authorization form signed and dated by the patient (or legal guardian) on file. This form, when filled out completely, complies with the HIPAA requirements concerning this authorization for release of information. You may print and compete this form and fax or mail to our patient services department:

4535 Dressler Rd
Canton,OH 44718

If you have any questions regarding an authorization please contact one of our patient services representatives. Contact Us

Assignment of Benefits Form

The Assignment of Benefits form is needed for MBFS to bill your auto insurance company. The form is attached to your medical bill, and lets the auto insurance company know to send payment directly to MBFS.

Worker’s Compensation Form

The Worker’s Compensation form contains all the needed information to bill your workers’ comp insurance or employer.

Liability Packet

The liability packet must be completed when you need MBFS to bill Auto Insurance for your visit.

Medical Claim Request Letter

Medical claim request letters must be completed by third parties when requesting a copy of a patient bill. For example, an attorney representing a patient in an automobile accident who needs a copy of the bill would need to return the medical claim request letter along with a HIPAA Authorization form.