Sugical Associates
Board Certified
INSURANCE INFORMATION
PRIMARY Insurance Company Name
Address
City
State
Zip
Insurance Phone
Group #
Policy #
Effective Date
Relationship to Subscriber(insured)
Subscriber Name
Subscriber's Employer
SECONDARY Insurance Company Name
Address
City
State
Zip
Insurance Phone
Group #
Policy #
Effective Date
Relationship to Subscriber(insured)
Subscriber Name
Subscriber's Employer
GUARANTOR INFORMATION
Guarantor Name(Last)
(First)
(Middle)
Relationship to guarantor to patient
Social Security Number
Address
City
State
Zip
Home Phone
Work Phone
ASSIGNMENT OF BENEFITS
I REQUEST THAT PAYMENT UNDER THE MEDICAL INSURANCE PROGRAM BE MADE TO SURGICAL ASSOCIATES, INC. ON ANY BILL FOR SERVICES FURNISHED ME DURING THE EFFECTIVE PERIOD OF THIS AUTHORIZATION AND I AUTHORIZE SURGICAL ASSOCIATES, INC. TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR MY INSURANCE COMPANY, OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS CLAIM OR ANY RELATED MEDICARE OR INSURANCE CLAIM. I FURTHER PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.
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x
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Signature of patient or responsible party to release information or authorize payment
I HAVE BEEN GIVEN AND HAVE READ SURGICAL ASSOCIATES,INC. FINANCIAL POLICY STATEMENT AND I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
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x
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Signature of patient or responsible party