Please include Pharmacy name, address, phone number and zip code.
Emergency Contact Information
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Rittenhouse Internal Medicine, P.C. or insurance company to release any information required to process my claims. If Medicare is my only insurance carrier, I understand that I am fully responsible for my 20% co-insurance due after Medicare payment.