In Case of Emergency (Friend or Relative not listed above)
INSURANCE INFORMATION (A copy of ALL Insurance cards is required for filing purposes.)
Your receipt for each visit will contain all the information needed to process an insurance claim. Please remember that insurance is a method of reimbursing you for fees paid to the doctor and is not a substitute for payment.
I hereby assign to Sandra Maerzacker, MD all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. The above registration information is correct to the best of my knowledge and I understand and accept the above payment policy.
I hereby authorize Sandra Maerzacker, MD to release any pertinent medical information to my insurance carriers for myself or dependents.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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