ࡱ> :<9 bjbj A"E k0008h$0 .$:p`YXw0 [X  : MEDICARE / MAJOR MEDICAL BILLING AUTHORIZATION I request payment of authorized Medicare/Major Medical benefits be made on my behalf to the doctors of Fortney Eyecare Associates for any services furnished me by their doctors. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance coverage is indicated in Item 9 of HCFA 1500 claim form or elsewhere on other approved claims forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the doctor agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. MAJOR MEDICAL / SUPPLEMENTAL INSURANCE BILLING AUTHORIZATION I request payment of authorized services to be made on my behalf, to Fortney Eyecare Associates for any services furnished. I authorize any holder of medical information about me, to release to my insurance company, any information needed to determine these benefits or the benefits payable for related services. I understand that the Fortney Eyecare Associates submits insurance claims through the Eyefinity Eclaim System and I authorize them to do so. I hereby authorize payment directly to the Fortney Eyecare Associates and its doctors for medical benefits, otherwise payable to me, for their services. I am aware Fortney Eyecare bills my insurance: . My Primary Doctor Is: Phone# : (They will be contacted for a referral if required) I am responsible for any rejections, denied claims, deductibles or copays __________________________________ _________________________ Patient Signature Date For Office use only: . Medical auth.doc     FEA FORTNEY EYECARE ASSOCIATES ADVANCE \u10 DEARBORN 23469 Michigan Avenue Near Outer Drive Dearborn, Michigan 48124 (313) 565-5600 FAX: (313) 562-3000 LIVONIA 37673 Five Mile Road Corner Newburgh Road Livonia, Michigan 48154 (734) 464-4441 FAX: (734) 464-4479 WARREN 3824 Thirteen Mile Road Corner Ryan Road Warren, Michigan 48092 (586) 751-2600 FAX: (586) 751-4111 WESTLAND 6565 Wayne Road Corner Hunter Street Westland, Michigan 48185 (734) 729-4600 FAX: (734) 729-1411 YPSILANTI 2 North Huron Street Corner Michigan Avenue Ypsilanti, Michigan 48197 (734) 484-4400 FAX: (734) 484-4200 /0d e lm5kuvwxyξ篠rcrcrVD#htNjhKmy5CJOJQJ^JaJhKmy5CJOJQJ^JhtNj5>*CJOJQJ^J"htNjhKmy5>*CJOJQJ^J#htNjh65CJOJQJ^JaJh@aCJOJQJhKmyh@aCJOJQJaJhKmyh6CJOJQJaJhKmyh65CJOJQJaJh@a5OJQJh@aOJQJh6OJQJhKmyh6CJaJh6CJOJQJh6/0d e lmxy/012gd6 $ f!a$gdKmy $ f!a$gd6$a$$a$1$7$8$+.0rtξβ}l^MC5htNjh65CJOJQJh6CJOJQJ htNjhtNjCJOJQJ^JaJhKmyCJOJQJ^JaJ htNjhKmyCJOJQJ^JaJ#htNjhKmy5CJOJQJ^JaJ&htNjhtNj5>*CJOJQJ^JaJhKmyhKmyOJQJ^JaJhKmyCJOJQJ^JhKmyhKmy>*CJOJQJ^JhKmy>*CJOJQJ^J htNj5>*CJOJQJ^JaJ&htNjhKmy5>*CJOJQJ^JaJ1234DEFHIKLNOQTrstbh8Aû h6CJ h65CJh6 h6>*CJjh6CJU h6CJ h65CJ h65CJhS"jhS"Uhkh6CJOJQJ^Jhkh&OJQJ^Jhkh6OJQJ^JhtNjOJQJ^JhkOJQJ^J%24EGHJKMNPQs $$Ifa$ dp$Ifd$ &]^a$ $]^a$$a$gd&gdk&>Mabi#78BWn dp$If $$Ifa$wjhh`$a$gd& $]^a$~kd$$Ifxr o(4 xa $$Ifa$?0P:p@aBP/ =!"#$ % Dpi$$If!vh#v#v:V x55/ 44 xa^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH P`P Normal1$7$8$H$OJQJ_HaJmH sH tH V@V  Heading 1$$1$7$8$@&H$a$5CJOJQJP@P  Heading 2$1$H$7$8$@&5CJOJQJDA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List <& < Footnote Reference44 Header  !4 4 Footer  !@>@"@ Title $H$a$5CJOJQJDB@2D  Body Text $H$a$ CJOJQJX`BX 6 No Spacing1$7$8$H$OJQJ_HaJmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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