SANFORD E. POMERANTZ, M.D.
3601 S.W. 29TH, SUITE 103
TOPEKA, KANSAS 66614
Fax to: 4783808 or E-Mail: [email protected]
BILLING DATA FORM AND INSURANCE WAVIER
PRIMARY INSURANCE : ___________________________________________
INSURANCE ID NUMBER: ____________________________
PATIENT’S NAME: LAST: ______________________ FIRST: _____________ MI: __
BIRTH DATE: _______ SEX: ___
RELATIONSHIP TO INSURED (circle): SELF- SPOUSE- CHILD
ADDRESS: _______________________________________
City: ___________________ZIP CODE: ________________
EMPLOYER’S NAME: _____________GROUP NAME AND NUMBER: ____________
OTHER INSURANCE? (Y N) __________________________________________
INSURED NAME: LAST: ______________________ FIRST: _____________ MI: __
BIRTH DATE: _______ SEX: ___
INSURED ADDRESS IF DIFFERENT: _____________________________________
ZIP CODE: ______
PHONES: Work: ___________ Home: ___________ Cell: ________________
BY MY SIGNATURE BELOW I UNDERSTAND THAT I WILL PAY FULL FEE IF INSURANCE DOES NOT PAY OR I MISS OR CANCEL ANY SCHEDULED APPOINTMENTS.
LINES 12 & 13 FORM 1500:
I authorize the release of any medical information to process this claim. I authorize payment of Medical benefits to Dr. Pomerantz. Since no bills will be sent to me, I will send Dr. Pomerantz any unpaid Balance due as indicated on insurance statements, otherwise there will be a $35 service fee and interest charges.
Co-payments will be collected at the time of service (There will be a $35 charge for all returned checks)
SIGNATURE ON FILE:______________________________ DATE: ________
COPAY DUE TODAY: $____________
AUTHORIZATION NUMBER(If Required):____________________________
Phone/Fax: (785) 478-3808
3601 S.W. 29TH, SUITE 103
TOPEKA, KANSAS 66614
Fax to: 4783808 or E-Mail: [email protected]
BILLING DATA FORM AND INSURANCE WAVIER
PRIMARY INSURANCE : ___________________________________________
INSURANCE ID NUMBER: ____________________________
PATIENT’S NAME: LAST: ______________________ FIRST: _____________ MI: __
BIRTH DATE: _______ SEX: ___
RELATIONSHIP TO INSURED (circle): SELF- SPOUSE- CHILD
ADDRESS: _______________________________________
City: ___________________ZIP CODE: ________________
EMPLOYER’S NAME: _____________GROUP NAME AND NUMBER: ____________
OTHER INSURANCE? (Y N) __________________________________________
INSURED NAME: LAST: ______________________ FIRST: _____________ MI: __
BIRTH DATE: _______ SEX: ___
INSURED ADDRESS IF DIFFERENT: _____________________________________
ZIP CODE: ______
PHONES: Work: ___________ Home: ___________ Cell: ________________
BY MY SIGNATURE BELOW I UNDERSTAND THAT I WILL PAY FULL FEE IF INSURANCE DOES NOT PAY OR I MISS OR CANCEL ANY SCHEDULED APPOINTMENTS.
LINES 12 & 13 FORM 1500:
I authorize the release of any medical information to process this claim. I authorize payment of Medical benefits to Dr. Pomerantz. Since no bills will be sent to me, I will send Dr. Pomerantz any unpaid Balance due as indicated on insurance statements, otherwise there will be a $35 service fee and interest charges.
Co-payments will be collected at the time of service (There will be a $35 charge for all returned checks)
SIGNATURE ON FILE:______________________________ DATE: ________
COPAY DUE TODAY: $____________
AUTHORIZATION NUMBER(If Required):____________________________
Phone/Fax: (785) 478-3808