Insurance Authorization

By entering my name below, I request that payment of authorized Medicare, Medicaid or other insurance benefits be made on my behalf to J Shoshana & Associates, for any services furnished to me by the listed provider/supplier.

[YES]  I understand that my signature requests that; payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

In Medicare assigned cases, the provider or supplies agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and noncovered services. Co-insurance and the deductible are based upon the charge determination of the insurance carrier.

[YES]  I understand that my signature requests that; payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

In Medicare assigned cases, the provider or supplies agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the insurance carrier.