Statement for payment of Medicare benefits.
Statement for payment of Medigap benefits.

I request that payment of authorized Medicare benefits be made on my behalf to the provider for any services furnished me by the listed provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.

I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorized release of information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered service. Coinsurance and the deductible are based upon the determination of the medicare carrier.

Provider Name:
M. Alan Goodson, M.D.
Provider #12982

Provider Name:
Guy H. Handley, M.D.
Provider #19602

Signature of Beneficiary:
Date Signed: