Include street address, city, state and zip code
This will only be used to send you appointment messages.
Insurance Information - please enter your primary and secondary (if applicable) insurance information.
Secondary (if applicable)
Insurance Release of Information, Authorization and Assignment: I request that payment of authorized Medicare or other
insurance company/carrier be made on my behalf to F. Parker Thornton M.D. L.L.C. for any services furnished to me by that party
who accepts assignments/physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of
medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or
its intermediaries any information needed for this or a related Medicare claim/other insurance company claim. I permit a copy of
this authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts
assignment. I understand it is mandatory to notify the healthcare provider of any other party who may be responsible for paying for
my treatment.(Section 1128B of the Social Security Act and U.S.C. 3801-3812 provides penalties for withholding this information.)
Please submit, thank you.