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KESPARA MEDICAL CENTER
22 Meridian Rd, Suite 10 Edison, NJ 08820
22 Meridian Rd, Suite 10 Edison, NJ 08820
Pullin Patel,MD
Internal Medicine
Ph:(732) 243-9808
Fax:(732) 791-5765
Patient Insurance Form

PATIENT NAME:

DATE:

PATIENT NAME:

Primary Insurance:

Subscriber Name:

Subscriber Birth Date:

Subscriber Social Security:

Employer:

Effective Date:

ID#:

Group Policy#:

Insurance Address:

Subscriber Name:

Secondary Insurance:

Subscriber Birth Date:

Subscriber Social Security:

Employer:

ID#:

Effective Date:

Group Policy#:

Insurance Address:

I certify that(or my dependants) have insurance coverage with the above listed companies and assign directly to P . Patel all insurance benefits , if any, otherwise payable to me for services rendered. I uderstand that I am personally responsible for all financial charges whether or not paid by the insurance company. I authorize the use of my signature of all insurance submissions. Dr. P. Patel may use my health care information and may disclose such information to the above named insurance company(ies) , and their agents for the purposes of obtaining payment  for services rendered and determining insurance benefits , or the benefits ,payable for related services.

I request that payment of authorized Medicare benefits and , if applicable, Medigap benefits made either to me or on my behalf to Dr. P. Patel , for any services furnished to me by the provider. To extend the permitted by law , I authorize any holder of medical or other information needed to determine these benefits or brnrfits for related services.

Signature of Beneficiary, Guardian or Representative:

PRINT NAME:

DATE: