Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Dialysis Center Billing Authorization Form
Patient Full Name *
Date of Birth
____ / ____ / ________
Medicare Beneficiary Identifier
Medicare Primary or Secondary Payer
Secondary Insurance Provider
Carrier
Member ID
Group number
Subscriber name
Assignment of Benefits Authorization
Your practice's consent wording goes here.
Signature
Date
Recurring Treatment Billing Consent
Financial Hardship Assistance Interest
Patient Signature
Date
Dialysis Center Billing Authorization Form template from formisoft.com. formisoft.com/intake-templates/dialysis-center-billing-authorization