Payment Options

Ins. Co.	Type	Prim/Sec	Eff. Start	Eff. Stop

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Add Patient Payment Options

Type

Insurance Company

Billing Order

Relationship to Insured

Insured's name

Last name

Insured's Date of Birth

Subscriber ID

Group Number

Effective Start Date

Effective Stop Date

Insurance billing authorization

I hereby authorize payment directly to this medical office, for any services rendered to me by the clinicians or any of its authorized agents. I authorize the release of all medical information to the insured’s health insurance carrier that is:
1) acquired in the course of my examination or treatment and
2) which may have a bearing on the benefits payable under this or any other plan that provides benefits or services.
I authorize this office or any of his authorized agents to assist me in obtaining payment from my health insurance companies. I authorize a copy of this “Signature on File” form to be used in place of the original and that this copy may be used on all my insurance submissions.