Patient Information (Page 2 of 2) in pdf

Patient Information Page 2

ACPM PODIATRY GROUP, LTD.

Dr. Curtis Ward

Dr. Anthony DeCeanne

Dr. Brent Parry

SIGNATURE ON FILE

I authorize the doctor named above to use my name on any and all claims or documents that

relate to health insurance benefits due to me and my dependents.

I authorize release of any information related to any claims to all my Insurance Companies or

other relevant parties.

I understand that I am responsible for my bill and agree to pay all charges for services and items

provided to me.

I authorize my doctor to act as my agent in helping me obtain payment from my Insurance

Companies.

I authorize payment of health benefits otherwise payable to me, directly to my doctor.

I permit a copy of this authorization to be used in place of the original.

This “Signature on File” is valid for one year from the date indicated below.

Signature of Beneficiary, Guardian or Personal Representative

Medicare #

Date

(if applicable)

Please print name of Beneficiary, Guardian or Personal Representative

Relationship to

Beneficiary

Form No. ACPM-PF2012

Patient Information Page 2