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Book Your Screening Colonoscopy Now

img page title1 Book Your Screening Colonoscopy Now

First Name:

Last Name:

Home Address:

City:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

EXT:

Home Address:

Date of Birth:

Employer Name:

Occupation:

Employer Address:

Spouses Name:

Primary Insurance:

Name of Insured:

Secondary Insurance:

HMO?

Authorization Required?

Co Pays:

Name of Medical Group:

Referred by:

In Case of Emergency Call Name:

Phone#:

Relationship:

I here by authorize payment of medical benefits billed to my insurance to:


I HEREBY ACCEPT RESPONSIBILITY FOR PAYMENT FOR ANY SERVICE(S) PROVIDED TO ME THAT IS NOT COVERED BY MY INSURANCE.I ALSO ACCEPT RESPONSIBILITY FOR FEES THAT EXCEED THE PAYMENT MADE BY MY INSURANCE,IF THE PRACTICE DOES NOT PARTICIPATE WITH MY INSURANCE. I AGREE TO ALL CO-PAYS, DEDUCTABLES AND CO-INSURANCE AT THE TIME OF SERVICE.

Signature:

Date:


It was a good experience. He is intelligent and listened to me well. He transmitted me confidence and competence in a friendly manner.

Paulo M. - 7/23/2013

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