Insurance Billing Authorization Form printable pdf download

Insurance Billing Authorization Form

Eden Medical Plaza

Plaza Real

20126 Stanton Ave. #205

39210 State St. #100

Castro Valley, CA 94546

Fremont, CA 94538

Phone 510.537.4211

INSURANCE BILLING AUTHORIZATION FORM

This form authorizes the The Hearing Center of Castro Valley to use or disclose your patient

health information to bill Medicare, Medi-Cal, CCS, or your private insurance company for

hearing evaluation and/or hearing aid purchase.

“I request that payment of authorized Medicare, Medi-Cal, CCS and/or other insurance

benefits be made on my behalf to The Hearing Center of Castro Valley for services provided

me by The Hearing Center of Castro Valley, its agents, and employees. I authorize any holder

of medical information about me to release to The Hearing Center of Castro Valley, Medicare,

Medi-Cal, CCS, and/or any other insurance company including its agents and employees, any

information or documentation needed to determine these benefits or the benefits payable for

related services.”

“I understand my signature requests that payment be made and authorizes release of medical

information necessary to secure payment for the claim. If I have supplemental health

insurance coverage, my signature authorizes releasing the medical information to the

supplemental insurance company, its agents, and employees. This signature authorization

shall remain in effect until revoked by me in writing. I understand that The Hearing Center of

Castro Valley is HIPPA compliant and I have the right to request a copy of The Hearing

Center of Castro Valley’s Privacy Notice and to review it before signing this authorization

form. A photocopy of this authorization is to be considered as valid as an original.”

BILLING YOUR INSURANCE DOES NOT GUARANTEE PAYMENT.

THE AMOUNT PAID BY INSURANCE CANNOT BE GUARANTEED.

YOU ARE RESPONSIBLE FOR THE PAYMENT OF YOUR BALANCE.

Patient’s Name (PRINT):

Patient’s Signature:

Date:

Primary Insurance:

Subscriber’s Name (if other than patient):

Subscriber’s Date of Birth:

Secondary Insurance:

Subscriber’s Name (if other than patient):

Subscriber’s Date of Birth:

Insurance Billing Authorization Form