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Bryan Physician Network Patient Information Form

* Denotes required fields; however, we request that you complete all fields as much as possible. This will help us prepare for your visit and will prevent the need for you to answer these questions when you arrive.

Patient Information

Gender

Patient Employment Information

Guarantor/Person Responsible for Payment

 

Insurance Information

Do you have Secondary Insurance?

Additional Information

Medicare Beneficiary Authorization

As a Medicare beneficiary/patient, I request that payment of authorized Medicare benefits be made to Bryan Physician Network. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits payable for related services.

Authorization to Treat and Financial Responsibility

I consent to medical treatment of the named patient.

I authorize the release of any medical information necessary to process insurance claims. I assign those benefits to which I am entitled, for services provided by Bryan Physician Network. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as the original.

I agree to be financially responsible and make payments to Bryan Physician Network for all services provided.

I have read and understand this information.
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