STATEMENT FOR PAYMENT OF MEDICARE BENEFITS
I request that payment of authorized Medicare benefits be made either to me or on my behalf to
Dr. Saliski, Williams, Ensminger, Vyas, Noriega, Bansal, Gribben and Mohammed for any services or items furnished to me by the physician or supplier. I authorize any holder of medical information about me to release to the health care financing Administrator and its agents any information needed to determine these benefits or the benefits payable for related services.
I authorize any holder of medical information about me to release to (name of MEDIGAP insure)
Any information needed to determine these benefits or the benefits payable for related services.
In submitting claims under this procedure ,PHYSICIANS undertake.
NOTE:THE FOLLOWING STATEMENT MUST BE SIGNED BY THE DME SUPPLIER PRIOR TO AUTHORIZATION OF PAYMENT FOR RENTAL OF DURABLE MEDICAL EQUIPMENT IN ASSIGNMENT CASES.
This supplier assumed unconditional responsibility for refunding of all overpayments for assigned claims for rental of durable medical equipment that may result from the failure of the Carrier to receive prompt notice of the return of,or the end of need for the rental of equipment ,or the death or institutionalization of the Beneficiary.