Insurance Information | East Alabama Primary Care

PRIMARY INSURANCE:

REFERRAL REQUIRED:

CONTRACT (or) ID #:

GROUP NUMBER:

NAME OF INSURED:

RELATIONSHIP TO PATIENT:

SECONDARY INSURANCE:

REFERRAL REQUIRED:

CONTRACT (or) ID #:

GROUP NUMBER:

NAME OF INSURED:

RELATIONSHIP TO PATIENT:

WE DO NOT ACCEPT PERSONAL CHECK'S / ALL CO-PAY'S / BALANCES ARE DUE NOW.

ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY PLEASE READ:

I AUTHORIZE PAYMENT OF ALL INSURANCE BENEFITS, BASIC AND MAJOR MEDICAL, FOR THIS PERIOD OF MEDICAL, EMERGENCY AND OR DIAGNOSTIC TREATMENTS TO BE MADE DIRECTLY TO EAST ALABAMA PRIMARY CARE, DR. SARAT MEKA / DR. RUBY POWAR. | UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE PLAN, INCLUDING BUT NOT LIMITED TO CO-PAYS, DEDUCTIBLE, NON-COVERED CHARGES, PROFESSIONAL FEES. | WILL BE RESPONSIBLE FOR ANY COLLECTION FEES, COURT COST AND / OR ATTORNEY FEES INCURRED BY E.A.P.C. /DR. SARAT MEKA, DR. RUBY POWAR,FOR PARTICIPATING IN MY CASE. WHILE COLLECTING ON MY ACCOUNT, PHOTOCOPIES OF THIS AUTHORIZATION ARE AS THE ORIGINAL. | AUTHORIZE E.A.G.M.S., IT'S EMPLOYEES AND AGENTS TO CONTACT ME AT ANY / ALL PHONE NUMBERS INCLUDING CELL PHONE NUMBER FOR THE PURPOSE OF TREATMENT, INSURANCE AND PAYMENTS ETC. BY SIGNING BELOW § UNDERSTAND MY RIGHTS AND RESPONSIBILITY AS A PATIENT ON E.A.P.C.

PATIENT NAME*

PATIENT / or RESPONSIBLE PARTY SIGNATURE*

RELATIONSHIP TO PATIENT

EMAIL ADDRESS*