Assignment of Insurance benefits & Eligibility Check

Primary Insurance Plan

Medicare Patients Only

Other Insurance Coverage

I hereby authorize and request that payments or authorized Medicare/other insurance company benefits made on my behalf, be paid directly to Langer Family Medicine, P.A. for any medical or surgical services rendered to me or a member of my family. I authorize any holder of medical or other information about me be release to the Social Security Administration, Health Care Financing Administration, its agents or carriers or the insurance company information needed for this or related Medicare/other insurance claim to determine these benefits or other benefits payable for related services. I understand that it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment.

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.