I authorize the release of any medical information to process this claim.I permit a copy of this authorization to be used in place of the original.
I hereby authorize Dr Patricia Wade to apply for benefits on my behalf for covered services rendered by her. I request payment from my insurance company be made directly to Dr Patricia Wade (or the party who accepts assignment)
I agree that printing my name in this box is electronically signing this document
I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of original. This authorization may be revoked by either me or the insurance company at any time in writing.
I agree that printing my name in the above box represents me signing this form
