Insurance Authorization

Patient Information

Insurance Information

Authorization

I authorize my insurance company to pay any and all benefits directly to Dr. Donna Vann for services rendered.

I authorize the use of my signature on all insurance submissions.

I authorize Dr. Vann to release any information necessary to process my insurance claims.

​​​​​​​I understand that I am financially responsible for all charges not covered by insurance, including deductibles, co-pays, and non-covered services