PAYMENT REQUESTED AT TIME OF SERVICE - UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical/medical benefits to Zaladonis Dermatology Associates for services rendered by providers in person or under supervision. I understand that I am financially responsible for any balance not covered by my insurance.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Zaladonis Dermatology Associates to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
MEDICARE - MEDICAID
I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.
A photocopy of these assignments shall be valid as the original.