Medicare Patient Authorization Form

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Medicare Authorization Form
I request that payment of authorized Medicare benefits be made either to me or on
my behalf to the Michigan Eyecare Institute, PC for any services furnished me by that
physician or supplier. I authorized any holder of medical information about me to
release to the Health Care Financing Administration and its agents any information
needed to determine these benefits payable to related services.
I understand my signature requests that payment be made and authorizes release of
medical information necessary to pay the claim. If other health insurance coverage is
indicated in Item 9 of the HCFA-1500 claim form or elsewhere on other approved
claim forms or electronically submitted claims, my signature authorizes releasing of
the information to the insurer or agency shown.
In Medicare-assigned cases, the physician or supplier agrees to accept the charge
determination of the Medicare carrier as the full charge, and the patient is responsible
only for the deductible, coinsurance, and non-covered services. Coinsurance and
deductible are based upon the charge determination of the Medicare carrier.
I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE ABOVE.
______________________________________________
Print Name
_________________________________
__________
Signature
Date
(Parent or Guardian Signature Required If Minor)
----------------------------------------------------------------------------------------------------------------------------------------------------------------
MEI DEARBORN: 5050 Schaefer Rd, Dearborn, MI 48126 | Phone: (313) 582-7440
MEI LIVONIA: 14555 Levan, Ste E-101, Livonia, MI 48154 | Phone: (734) 464-7800
MEI SOUTHFIELD: 29877 Telegraph Rd, Ste 100, Southfield, MI 48034 | Phone: (248) 352-2806 or (800) 676-EYES

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