Fillable Nsurance Signature And Information Release Form printable pdf download

Nsurance Signature And Information Release Form

Download a blank fillable Nsurance Signature And Information Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Nsurance Signature And Information Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Insurance Signature and Information

Release Form

D.A. BRODMANN, O.D.

Patient Name:________________________________________

I certify that the information given by me in applying for insurance and/or Medicare/Medicaid

payment is true and correct. I authorize my doctor to act as my agent in helping me to obtain payment

of my insurance benefits and I authorize payment of these benefits directly to D.A Brodmann, O.D. on

my behalf for any services and materials furnished.

I certify that Dr. Brodmann has made me aware of my rights under HIPPA, that a form is

available for me to read and review in her office and that I can alternately go to

at any time to print and save a copy of these rights afforded to me

under HIPPA.

I authorize any holder of medical information about me to release to the Healthcare Financing

Administration and its agents, or any like agency or information exchange, any information needed to

determine these benefits payable to related services.

If I have any other health insurance coverage or vision insurance coverage, my signature

authorizes the release of the above medical information to the insurer or agency shown and further

authorizes my doctor to act as agent on my behalf as shown above.

I agree to pay for ANY fees that my insurance company has denied and/or deems to be my

responsibility and/or any payments that may be due to the provider should they be credited toward an

applicable deductible or co-insurance as outlined by my insurance company. I also understand that it is

my responsibility to contact my insurance company to be made aware of any deductibles, co-insurances

or other out of pocket expenses that may be a part of my plan should I not be aware of these already.

Finally, I agree to pay out-of-pocket for any materials or services that are rendered outside my

dates of coverage (insurance that has lapsed or not yet gone into effect) or that are not covered by my

insurance plan.

X_________________________________________________

_________________________

Signature of Patient

Date

X_________________________________________________

__________________________

Signature of Parent/Guardian or Legal Representative

Date

CLEAR FORM

PRINT FORM

Nsurance Signature And Information Release Form

Related Articles

Related forms

Related Categories