legal insurance form

Phone: <a class="ecp-phone-call-phone" href="tel:718-618-7955" style="text-decoration:none"> 718-618-7955
Email: familyoptometry121@gmail.com (Do not send personal health information by email.)

Name: Family Optometry 121, PC
Address: 3300 Third Ave., Bronx, NY, 10456, US
Telephone: 718-618-7955

Patient Name*
First Last
Date of Birth
MM slash DD slash YYYY
MEDICARE/ INSURANCE AUTHORIZATION:*
I request that payment of authorized Medicare/Insurance benefits be made on my behalf to Dr. Aliya Hot for services furnished to me by the physician, I authorize any holder of medical information about me to be released to the Health Care Financing Administration’s and it’s agents any information needed to determine these benefits, or the benefits payable for related services. In addition, I permit a copy of this authorization to be used in place of the original for filing claims and other related services.
Patient’s Signature
NOTICE OF PRIVACY/ PATIENT ACKNOWLEDGEMENT*
I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.
Patient’s Signature*
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Date
MM slash DD slash YYYY
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to Patient
Name
Source of Authority