(1)Patient Information: (Full name as it appears on your Insurance Card)
(2)Patient’s Doctor: Please list your referring doctor and/or your Primary Care Physician
(3) Insured Status
Are you Insured by:
If yes, please note we are required by Medicare to submit claims for services we provide to you unless you do not permit us to file your claims.
If no, we will need to provide you with a different form.
If yes, we will need to provide you with a different form.
(4) Clinic Policies
Please initial below