NYC-Metro Physician Services, PC

NOTICE OF AUTHORIZATIONS AND ASSIGNMENT OF BENEFITS

Patient Name 	

Date of Birth 	 Date:  	

ASSIGNMENT OF INSURANCE BENEFITS:
I HEREBY AUTHORIZE DIRECT PAYMENT OF INSURANCE BENEFITS TO NYC-Metro Physician Services, PC or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision.  I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit.   I understand and agree that I will be responsible for any co-pay or balance due that NYC-Metro Physician Services, PC is unable to collect from my insurance carrier for whatever reason.

AUTHORIZATION TO RELEASE NON-PUBLIC INFORMATION:
I certify that I have read and been offered a copy of the NYC-METRO PHYSICIAN SERVICES, PC “Notice of Privacy Practices”. I hereby authorize NYC-METRO PHYSICIAN SERVICES, PC and/or the physician individually to release any of my or my dependent’s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits.

MEDICARE / MEDICAID INSURANCE:
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits be made directly to NYC-METRO PHYSICIAN SERVICES, PC or the physician on my behalf.

LAB/X-RAY/DIAGNOSTIC SERVICES:
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason.

PRESCRIPTIONS:
I acknowledge that my treating physician may obtain a prescription history if necessary.

Preferred Pharmacy / Location:                                                                        Phone #:                                           

CONSENT TO TREATMENT:
I hereby consent to evaluation, testing, and treatment as directed by my NYC-METRO PHYSICIAN SERVICES, PC physician or those under his/her supervision.

I have read and agree to all of the above information:

            PATIENT SIGNATURE:  	____DATE: 	____________

  GUARANTOR SIGNATURE: ___________	_____DATE: 	____________

                                                                                 (If different from patient)
  GUARANTOR NAME (Please Print):  _______	_______