Carlos A Lozano MD PA

Available Forms

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES Additional Insurance Information Form Appointment Request Authorization to Release Medical Information New Patient Information Form Notice of Privacy Practices Prescription Refill Request Request of Medical Records

Additional Insurance Information Form

Name of Insured

First, Middle, Last

Insured Relationship to Patient

Insured Date of Birth

Insured Social Security Number

Insured Employer, Address, Phone

Name, Address, City, State, Zip Code, Phone

Insurance Company

Policy #

Group #

Union/Local #

If applicable

Insurance Address *

Address, City, State, Zip Code

What is your Copay

$ Amount

How much is your Deductible

$ Amount

How much Deductible have you used

$ Amount

Max. Annual Benefit

$ Amount

By initialing, you agree to the statement below. *

I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.

Date

* Required field