• Medical Insurance Information Primary

  • Medical Insurance Information Secondary

  • I certify that I have read and agree to Drs. Lacey’s payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to Dr. Lacey all money to which I am entitled for medical expenses related to the services performed from time to time by Dr. Lacey. I authorize Dr. Lacey to release any medical information to my insurance carrier or third-party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balancing within 90 days of notification of the amount due will result in submission to an outside collection agency. A $30.00 returned check fee will be charged for checks returned due to insufficient funds.

    MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to Dr. Lacey. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.

  • Clear
  • Should be Empty: