Please note: Completion of this form will take 24 hours to process to the office.
and AcknowledgementI/we hereby state that the above information is true and accurate to the best of my/our knowledge. I/we authorize the above named practice to release any information acquired in the course of my treatment to my insurance company, employer,Physicians, Institutions, or third party payors as required for certain claims filed.
* I/we authorize direct payment to be made to the above named practice for any and all medical or surgical services rendered.I understand if any services or change are not covered by my insurance carrier or my eligibility can not be verified, I am responsible for all charges incurred.
FOR MEDICARE PATIENTS: THIS OFFICE ACCEPTS BASIC MEDICARE ASSIGNMENTS. MEDICARE
PAYS 80% OF THE AMOUNT THEY APPROVE AFTER YOU HAVE MET YOUR DEDUCTIBLE. YOU ARE
RESPONSIBLE FOR YOUR DEDUCTIBLE AND THE REMAINING 20%. IF YOU HAVE A SECONDARY INSURANCE
THAT COVERS THE REMAINING 20% PLEASE PROVIDE US WITH THAT INFORMATION.
* Submitting an application through this website constitutes your electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been "signed" and will constitute an "original" when printed from electronic records established and maintained by Buckingham Facial Plastic Surgery.