David N. Buchalter, M.D. Steve E. Meadows, M.D. Russell D. Weisz, M.D ...
David N. Buchalter, M.D.
Orthopedic Surgeon Diplomate, Board Certified by A.B.O.S.
Brian E. Coleman, M.D.
Board Certified Foot & Ankle Specialist Diplomate, American Board of Orthopedic Surgery
Steve E. Meadows, M.D.
Diplomatic American Board of Orthopedic Surgery General Orthopedics, Subspecialty in Shoulder, Elbow, Wrist & Hand Surgery
William P. Toole, M.D.
Sports Medicine, Arthroscopic Surgery Cartilage Restoration
Hip Arthroscopy and Preservation
Russell D. Weisz, M.D.
Orthopedic Surgeon, Board Certified Adult Trauma and Reconstruction Geriatric Fractures
Jonathan M. Tarrash, M.D.
Board Certified in Pain Medicine Physical Medicine and Rehabilitation
MEDICARE EXTENDED AUTHORIZATION "SIGNATURE ON FILE"
______________________________ BENEFICIARY NAME (HIC)
______________________________ MEDICARE HEALTH INSURANCE NUMBER
I request that payment of authorized Medicare benefits be made either to me, or on my behalf, to ______________________________ for any services furnished
to me by that physician. I authorize any holder of medical information about me to release to the CMS and its agents, any information needed to determine these benefits or benefits payable for related services.
______________________________
PATIENT NAME
______________
DATE
MEDIGAP ASSIGNMENT OF BENEFITS
To: ______________________________ MEDIGAP INSURANCE CARRIER
______________________________ BENEFICIARY NAME
______________________________ MEDIGAP INSURANCE POLICY NUMBER
I request that payment of authorized Medigap benefits be made either to me or on my behalf to ______________________________ for any services furnished to me by that physician/supplier. I authorize any holder of medical information about me to release to the above-mentioned insurance carrier, any information needed to determine these benefits payable or benefits payable for related services.
______________________________
PATIENT SIGNATURE
______________
DATE
Linton Medical Park ? 4800 Linton Boulevard, Bldg. A ? Delray Beach, FL 33445 ? (561) 496-6622 ? Fax (561) 496-6577
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