First-Call Medical, Inc. - Nationwide 24-Hour Holter, Event, and Pacemaker Monitoring


Secure Patient Authorization Form

Monitor Information:*  







 
 
 
Patient Information:
Sex:  

Primary Insurance Information:
 
Relationship of Patient to the Subscriber:      

Secondary Insurance Information:
 
Relationship of Patient to the Subscriber:      

   
 

Physician Or Account Information:
 

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.

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

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