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INSURANCE SIGNATURE FORM
Patient Name:
 
Patient Soc. Sec. No
D.O.B.
Name of Primary Insurance Co.:
Policy Number:
Group Number:
Name of Policy Holder:
Policy Holder's Soc. Sec. No.:
Relation to Patient:
D.O.B. of Policy Holder:
Policy Holder's Place of Employment:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name of Secondary Insurance Co.:
Policy Number:
Group Number:
Name of Policy Holder:
       
RELEASE OF INFORMATION / PAYMENT AUTHORIZATION
I authorize release of any medical information from Dankner Fiergang Eye
Associates to process insurance claims on my behalf. I authorize payment of
medical benefits directly to the physician or supplier for myself and/or dependents as listed above. I certify that the information I have reported with regard to my insurance coverage is correct. I understand I am responsible for any deductibles, co-insurancel or amounts for services not covered by the insurance carrier. This authorization is valid for 12 months from the date entered below.
Date: Signature:
 
FOR OFFICE USE ONLY
Pat#: Date Entered: Int: