Date of Birth:
Name of Insured:
Name of Medical Group:
In Case of Emergency Call Name:
I here by authorize payment of medical benefits billed to my insurance to:
Gustavo A. Machicado M.D, FACP, FACG Saleem A. Desai M.D, FACP, FACG
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.
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Truly devoted to his patients, Dr. Desai always puts their needs first – and uses cutting-edge technology to get them back to health as swiftly as possible.
S. Hameed - 2/16/2013
For Appointment call: 1-888-49-COLON
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