First Call Medical - Secure Patient Authorization Form

Secure Patient Authorization Form

Monitor Information:*
Holter Monitor	In-Home Service Request
Looping Cardiac Event Monitor	Duration:*	Duration:*
Non-Looping Cardiac Event Monitor	Monitor Applied in Office
Blood Pressure Monitor	Monitor Serial #:
Mobile Cardiac Telemetry
Patch Extended Holter
Patch Wireless Event
Patch Mobile Cardiac Telemetry

Patient Information:

Last Name:* First:* MR#:*

Email Address: Sex: Male Female D.O.B.*

Address:* City:* State:* Zip:*

Home Phone:* Work: Cell:

Patient Information:
Last Name:*	First:*		MR#:*
Email Address:	Sex:	Male Female	D.O.B.*
Address:*	City:*		State:*	Zip:*
Home Phone:*	Work:		Cell:

Primary Insurance Information:

Company: Attention:

Address: City: State: Zip:

Phone: Website:

Policy/Group #: Identification #:

Subscriber Name: Subscriber's Social Security #:

Relationship of Patient to the Subscriber: Self Spouse Child

Primary Insurance Information:
Company:	Attention:
Address:	City:	State: Zip:
Phone:	Website:

Secondary Insurance Information:

Company: Attention:

Address: City: State: Zip:

Phone: Website:

Policy/Group #: Identification #:

Subscriber Name: Subscriber's Social Security #:

Relationship of Patient to the Subscriber: Self Spouse Child

Secondary Insurance Information:
Company:	Attention:
Address:	City:	State: Zip:
Phone:	Website:

Diagnosis and/or Indications for Test:*

Physician Or Account Information:

Physician Last Name:* Physician First Name:*

Practice Name:* Email:

Pager Number: Physician E-Signature:

Address: City: State: Zip:

Phone:* Fax:

Diagnosis and/or Indications for Test:*

Physician Or Account Information:
Physician Last Name:*		Physician First Name:*
Practice Name:*		Email:
Pager Number:		Physician E-Signature:

Patient Authorization Statement:
I authorize any holder of medical or other information about me to release to the carrier(s) listed above any information needed to process this claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits for technical component cardiac service to First-Call Medical, Inc., which accepts assignment on this claim. I acknowledge that any services not covered by my insurance will be my responsibility. I also acknowledge responsibility for the assigned monitor to be returned in proper working order upon completion of service. Failure to do so will result in a charge billed directly to me to cover the replacement costs of the monitor. I have read the Notice of Privacy Practices and Patient Authorization for Disclosure of Protected Health Information materials.

Patient E-Signature: Date:

First Call Medical, Inc.
Nationwide 24-Hour Holter, Event, and Pacemaker Monitoring
28 Andover Street, Ste 200 | Andover, MA 01810
800 274 5399
info@fcminc.com

Policy/Group #:		Identification #:
Subscriber Name:		Subscriber's Social Security #:
Relationship of Patient to the Subscriber: Self Spouse Child

Patient Authorization Statement: I authorize any holder of medical or other information about me to release to the carrier(s) listed above any information needed to process this claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits for technical component cardiac service to First-Call Medical, Inc., which accepts assignment on this claim. I acknowledge that any services not covered by my insurance will be my responsibility. I also acknowledge responsibility for the assigned monitor to be returned in proper working order upon completion of service. Failure to do so will result in a charge billed directly to me to cover the replacement costs of the monitor. I have read the Notice of Privacy Practices and Patient Authorization for Disclosure of Protected Health Information materials.
Patient E-Signature:		Date: