FOR MEDICARE PATIENTS

PLEASE READ AND SIGN THE FOLLOWING.
WHEN IT IS COMPLETED RETURN IT TO THE OFFICE RECEPTIONIST.

CONSENT TO PAY AGREEMENT
The ___________________________________ exam that you are about to have may or may not be covered by the Medicare Program. We will do everything possible to assist you in collecting the payment for your claim, including rebilling the Medicare Necessity Appeals Board. I agree to pay if Medicare does not.


X_______________________________________________________________ ______/______/______
SIGNATURE DATE

NOTE: Must be signed by the Beneficiary or the Beneficiary's legally appointed representative.

MEDICARE SIGNATURE AUTHORIZATION



NAME OF BENEFICIARY ______________________________________________________________



MEDICARE NO. (HIC NO.) _____________________________________________________________


I request that payment of authorized Medicare benefits be made either to me or on my behalf to Faith Carlin, M.D. for any services furnished me by Faith Carlin, M.D. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductable, coinsurance, and noncovered services. Coinsurance and the deductable are based upon the change determination of the Medicare carrier.

X_______________________________________________________________ ______/______/______
SIGNATURE DATE




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Updated: January 11, 1998