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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He was professional, courteous, quick, and knew his stuff.
Michael G. - 1/14/2013
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