Insurance Billing Authorization Form Page 2

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Insurance Provider: 
 
________________________________________  
 
ID Number ______________________________ 
 
Group Number __________________________ 
 
Secondary Insurance: _______________________ 
 
ID Number   ______________________________ 
 
PPO/HMO  [circle one] 
 
Referred by:  _____________________________   
 
Required for Medicare /HMO 
 
Provider phone number [on back of card] ________ 
If you can send a copy of front and back of your insurance card  

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