BRADLEY K BECKER - Cosmetic Surgery, Plastic &

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

PATIENT RESPONSIBILITY FORM

1. INDIVIDUAL'S FINANCIAL RESPONSIBILITY

  • I understand that I am financially responsible for my health insurance deductible, coinsurance or noncovered service.
  • Co-payments are due at time of service.
  • If my plan requires a referral, I must obtain it prior to my visit.
  • In the event that my health plan determines a service to be "not payable", I will be responsible for the complete charge and agree to pay the costs of all services provided.
  • If I am uninsured, I agree to pay for the medical services rendered to me at time of service.

2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

  • I hereby authorize and direct payment of my medical benefits to Dr. Bradley Becker,
    D.O., on my behalf for any services furnished to me by the providers.

3. AUTHORIZATION TO RELEASE RECORDS

  • I request payment of authorized Medicare benefits t me or on my behalf for any services furnished me by or in Dr. Bradley Becker,D.0. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.

4. MEDICARE REQUEST FOR PAYMENT

  • I request payment of authorized Medicare benefits t me or on my behalf for any services furnished me by or in Dr. Bradley Becker,D.0. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
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