Patient Info

Patient's Sex:

Male
Female
Born Physically Male
Born Physically Female

Race:
Cauc.
Afr. Amer.
Hisp.
Asian
Other

Marital Status:
Single
Married
Seperated
Widow/Widower
Divorced

Employment
Full
Part
Retired
Unemployed

Bill To

Primary Coverage

Patient Relationship to Insured
Self
Spouse
Son
Daughter
Other
Disable

Secondary Coverage

Patient Relationship to Insured
Self
Spouse
Son
Daughter
Other
Disable

Authorization

THE ABOVE SUBSCRIBER HEREBY AUTHORIZES HIS/HER INSURANCE COMPANY TO ISSUE IDEMNITY CHECKS TO
THE ABOVE LISTED MEDICAL PROVIDER FOR SERVICES PROVIDED.

I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services to the physician OR organization furnishing the services and authorize such physician OR organization to submit a claim to my insurance carrier OR Medicare for payment. I authorize any holder of medical or other information about me to release to insurance carriers OR the Health Care Financing Administration and its agents OR the Social Security Administration or its intermediaries OR any agency, group or person(s) necessary to secure payment any information needed for this or related Medicare claim. * For and in consideration of services rendered and to be rendered by the aboce listed medical provider, I herby guarantee payment of all charges incurred for this account. * The patient and his / her representative recognizing the need for health care, consents to the aboce listed medical provider rendering services as ordered by the physicians, including medical or surgical treatment, laboratory procedures, X-ray examinations or other services rendered under the general and specific instructions of the physicians. * I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct.