Patient Medical Insurance Information Form

PATIENT INFORMATION










PRIMARY INSURANCE







SECONDARY INSURANCE







PLEASE READ AND SIGN

I request that payment of authorized Medicare and private insurance benefits on my behalf be paid to Retina Associates of St. Louis, Inc for any service provided to me by David A. Glaser, MD, and/or Carla Territo, MD and/or B. Wayne Dudney, MD or associates. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. In the event this account is not paid in a timely manner, it will be turned over to a collection agency and collection fees will be applied.



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