INSURANCE AUTHORIZATION FORM

I request that payment of authorized medical insurance benefits be made either to me or on my behalf to Harry Marshak, MD for any services furnished to me byHarry Marshak, MD. I authorize any holder of medical information about me needed to determine the benefits payable for related services to be released to Harry Marshak, MD.

I understand my signature requests that payment be made and authorizes release of medial information necessary to pay the claim. If item 9 of the HCFA-1500 form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physicians agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is only responsible for the deductible, coinsurance, and non-covered charges. Coinsurances and deductible are based upon determination of the insurance carrier.

I hereby authorize and request my insurance company to pay directly toHarry Marshak, MD that amount(s) due on my claim for services rendered to my dependent(s) or to me. I further agree, should the amount be insufficient to cover the entire medical and surgical expense, I will be responsible for the difference, and if the nature of the services were such that they are not covered by the policy, I will be responsible toHarry Marshak, MD for payment of the entire bill.

If I do not get the proper authorization to be seen at Harry Marshak, MD, I will be responsible for all charges incurred. Please read your insurance information so that all of the plan requirements are clear to you. Questions should be referred to your health plan.


Printed Patient Name:_____________________________________


Insured’s Signature :_____________________________________

Print form, sign and return to
HARRY MARSHAK, MD, FACS OPHTHALMIC
PLASTIC AND FACIAL SURGERY

74-075 EL PASEO SUITE D2 PALM DESERT, CA 92260