Transcription of PATIENT’S REQUEST FOR MEDICAL PAYMENT
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PATIENT’S REQUEST FOR MEDICAL PAYMENT
IMPORTANT SEE OTHER SIDE FOR INSTRUCTIONSPLEASE TYPE OR PRINT INFORMATIONMEDICAL INSURANCE BENEFITS SOCIAL SECURITY ACTPATIENT S REQUEST FOR MEDICAL payments ignature of Patient (If patient is unable to sign, see Block 6 on reverse)Date signedNOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction be subject to fine and imprisonment under Federal law. No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (20 CFR ).FORM APPROVEDOMB NO 0938-0008 Name of Beneficiary from Health Insurance CardSEND COMPLETED FORM TO:(Last) (First) (Middle)1234563b4b4cPatient s SexClaim Number from Health Insurance CardnnMalennFemalePatient s Mailing Addr
PATIENT’S REQUEST FOR MEDICAL PAYMENT Signature of Patient (If patient is unable to sign, see Block 6 on reverse) Date signed ... • Doctor’s or supplier’s name and address. Many times a bill will show the names of several doctors or suppliers. ... no persons are required to respond to a collection of information unless it displays a ...
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