Korman Healthcare

Insurance Billing Authorization Form


Patient/Resident Name:

Patient/Resident Phone:

Patient/Resident Address:

Patient/Resident DOB:

Medication Allergies

  

Primary Insurance:

 

Secondary Insurance:

 

 

Insurance #1 I.D. #: (Prescription Benefits)

Insurance #2 I.D. #: (Prescription Benefits)

Insurance # 1 Group #

Insurance #2 Group #

Prescription BIN #:

Prescription BIN #:

Insurance # 1 Member Services Phone #:

  

Insurance #2 Member Services Phone #:

  

Primary Care Physician

Physician phone: Fax:

☑ CHILD SAFETY WAIVER: YOU AGREE TO WAIVE THE CHILD-RESISTANT SAFETY CAP REQUIREMENT  FOR ALL NEW PRESCRIPTIONS AND REFILLS.  BUBBLE PACK/BINGO CARDS/PRATA ARE NOT CHILD SAFE AND SHOULD BE KEPT OUT THE REACH OF CHILDREN AT ALL TIMES.

* * Insurance Authorization *** (Patient/Resident/Durable Power of Attorney Signature Required) * *

Patient/Resident/Durable Power of Attorney Name:

  

 

Patient/Resident/Durable Power of Attorney Address:

  

  

Patient/Resident/Durable Power of Attorney Phone:

  

Patient/Resident/Durable Power of Attorney Signature:

  

Date  

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Insurance Billing Authorization Form
lock iconUnique Document ID: 46971386abe29f0ffb1518a0e222ec1ba22ddea5
Timestamp Audit
June 11, 2020 3:59 pm EDTInsurance Billing Authorization Form Uploaded by Mark McKee - mmckee@box2394.temp.domains IP 24.112.194.235
June 11, 2020 6:45 pm EDTMike Lawson - michael@swooshweb.com added by Mark McKee - info@box2394.temp.domains as a CC'd Recipient Ip: 24.112.194.235
June 12, 2020 9:01 am EDTMike Lawson - michael@swooshweb.com added by Mark McKee - info@box2394.temp.domains as a CC'd Recipient Ip: 24.112.194.235
June 13, 2020 9:45 pm EDTMike Lawson - michael@swooshweb.com added by Mark McKee - info@box2394.temp.domains as a CC'd Recipient Ip: 24.112.194.235
June 13, 2020 9:49 pm EDTMike Lawson - michael@swooshweb.com added by Mark McKee - info@box2394.temp.domains as a CC'd Recipient Ip: 24.112.194.235
June 14, 2020 6:39 am EDTMike Lawson - michael@swooshweb.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.191.189
June 14, 2020 6:43 am EDTMike Lawson - michael@swooshweb.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.191.189
June 14, 2020 5:33 pm EDTMike Lawson - michael@swooshweb.com added by Mark McKee - mike@lawsonclan.com as a CC'd Recipient Ip: 24.112.194.235
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http://box2394.temp.domains/~ifcchamy/kormanhealthcare/
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