Medicare Patient Authorization Form

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MRI/MRA
LOCATION: ____________________________________
Imaging
Centers
Bio-Magnetic Resonance, Inc.
MRI/MRA
MEDICARE PATIENT AUTHORIZATION FORM
30781 Stephenson Highway
Imaging
MadIson HeIgHts, MI 48071
Centers
(248) 585-5115
FAX (248) 585-0234
Bio-Magnetic Resonance, Inc.
30781 Stephenson Highway
“I request that payment of authorized Medicare Benefits be made
MadIson HeIgHts, MI 48071
(248) 585-5115
on my behalf to Bio-Magnetic MRI/MRA Imaging Centers for any
FAX (248) 585-0234
services furnished to me by this provider.”
the Imaging Center
15670 Southfield Road
allen PaRk, MI 48101
(313) 294-2897
Patient’s Full Name (as it appears on card)
FAX (313) 294-2915
the Imaging Center
15670 Southfield Road
allen PaRk, MI 48101
HIC Claim Number
(313) 294-2897
FAX (313) 294-2915
Bio-Magnetic Resonance, Inc.
25100 Kelly Road
Marital Status:
RosevIlle, MI 48066
(586) 445-4900
Married _____________
Divorced _____________
FAX (586) 445-4902
Bio-Magnetic Resonance, Inc.
25100 Kelly Road
RosevIlle, MI 48066
Widowed ____________
Single ________________
(586) 445-4900
FAX (586) 445-4902
Biomagnetic Imaging Center
For services furnished to in-patients of a hospital or SNF, this request
960 River Centre Drive
PoRt HuRon, MI 48060
is effective for the period of confinement. For services furnished by a
(810) 966-8523
provider/supplier or on an outpatient basis, this request is effective
FAX (810) 966-5056
Biomagnetic Imaging Center
until revoked by the beneficiary.
960 River Centre Drive
PoRt HuRon, MI 48060
“I authorize any holder of medical or other information about me to
(810) 966-8523
FAX (810) 966-5056
release to the Social Security Administration and Health Care Financing
the Imaging Center
Administration or its intermediaries or carriers, any information
4447 Talmadge, Suite H
needed for this or a related Medicare claim. I permit a copy of this
toledo, OH 43623
authorization to be used in place of the original, and request payment
(888) 674-8653
FAX (888) 674-8650
the Imaging Center
of medical insurance to the party who accepts assignments.”
4447 Talmadge, Suite H
toledo, OH 43623
(888) 674-8653
FAX (888) 674-8650
(888) MRI-todaY
____________________________
________________________
(674-8632)
Patient Signature
Date
Rev. 4-6-09

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