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Home » Patient Resources » Forms » Insurance Signature on File & Assignment of Benefits Forms

Insurance Signature on File & Assignment of Benefits Forms

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Insurance Signature Form

  • I hereby authorize payment of medical benefits directly to Sohail N. Shaikh, MD or Center for Bariatric Endoscopy for any services rendered to me by Sohail N. Shaikh, MD.
    I understand and agree that I am responsible for the payment of any and all charges incurred as a result of this or any subsequent office visit(s) or procedures. I also understand and agree to accept responsibility for payment of any and all claims should my insurance carrier deny all or part of a claim.
    I understand and agree that all insurance deductibles and any incurred expenses not covered by the insured’s health carrier must be paid for at the time of services.
    I authorize Sohail N. Shaikh, MD or any billing company he is in contract with to complete any necessary insurance Claim Forms on my behalf and permit the release of any medical or other information which may be needed in order to process said claims. I authorize a copy of this “Signature on File” form to be referred to when insurance claim forms are submitted for healthcare services I have received (including to the Centers for Medicare & Medicaid Services and agents, along with any Medicare Supplemental Insurance carriers if applicable, in the case of Medicare).
 

Verification

 

“Individual results may vary.  Results are not guaranteed with this or any other procedure. Any weight loss procedure should be accompanied with nutritional counselling and an appropriate diet and exercise program.”