First Call Medical - Secure Patient Authorization Form

Secure Patient Authorization Form

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

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

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


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:

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

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