Insurance Authorization

Patient Information

Insurance Information

Authorization

I Authorize My Insurance Company To Pay Any And All Insurance Benefits Otherwise Payable To Me For Services Rendered To Dr. Donna Vann.

I Authorize The Use Of This Signature On Any And All Insurance Submissions ..

I Authorize Dr. Vann To Release Any And All Information Necessary To Secure The Payment Of
Benefits.

I Understand That I Am Financially Responsible For Any And All Charges Whether Or Not Paid
By Insurance.