FAITH CARLIN, M.D. | PATIENT REGISTRATION |
PLEASE COMPLETE AND RETURN TO RECEPTIONIST MEDICARE PATIENTS: FILL OUT PAGE 2 ALSO |
PATIENT INFORMATION | PRIMARY INSURED INFORMATION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Do you have a Secondary Insurance Plan? Yes
No
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Patient referred by:
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INSURANCE SIGNATURE AUTHORIZATION |
I authorize any holder of medical or other information about me to release
to the insurance company any information needed for this or a related claim. I permit
a copy of this authorization to be used in place of the original, and request payment
of medical insurance benefits to Faith Carlin, M.D.
X _______________________________________ |
PAYMENT TERMS:
We will bill your insurance as a courtesy, however you are responsible for the bill
whether or not your insurance pays.
We prefer payment on date of service. You may pay with cash or check.
A $7.00 rebilling fee (per month) may be added to all accounts with a pastdue
balance over 60 days.
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE COMPANY TO VERIFY THAT WE ARE
MEMBERS OF YOUR HEALTH PLAN PRIOR TO SERVICES.
I have read the above information
and agree to these terms presented:
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_________________ Signature Date