I hereby authorize the above physician (s) to release any information regarding services rendered by him and allow a photocopy of my signature to be used to file insurance, and grant permission for publication or presentation of my medical information or photographs for scientific/educational purposed only. I hereby authorize and direct my insurer to issue payment for benefits due me for services rendered by the above physician (s) to be made directly to him. Regardless of my insurance benefits, if any I understand I am financially responsible for the fees for services rendered.
Dated and signed by responsible party, policy owner or insured patient
If a Third Party Collection Agency becomes necessary due to an unpaid balance, a fee will be applied totaling 20% of the balance in addition to the amount owed.
I certify that the information given by me in applying payment under Title XVIII of the Social Security Act is correct. I authorize myholder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers anyinformation needed for this or related Medicare claim. I request the payment of authorized benefits be made on my behalf. I assignthe benefits payable for physician or organization furnishing the service or authorize such physician or organization to submit a claimto Medicare for payment for me.I request that payment under the medical insurance program be made either to me or to the above named physician (s)
I hereby authorize CGS to furnish to the above named physician any information regarding my Medicare claims under Title XVIII ofthe Social Security Act. I understand that this release will be valid one year from the date shown below unless I send a written noticeto the above Company that the authorization is to be withdrawn at an earlier date.
Don’t forget to fill out the Patient History Form as well.
Please contact Warwar Eye Group at 937-297-7676 if questions.
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