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Patient's Insurance Information Form

Please complete the online Insurance Form.  Required fields are identified with an "*" in the field name.  If you prefer to print out a copy and bring it to the office, please use the link in these instructions.  For new patients, please continue to the Medical Information and Billing Consent Form to fill out or update your information.

Please complete the online Insurance Form.  Required fields are identified with an "*" in the field name.  If you prefer to print out a copy and bring it to the office, please use the link below.  

Patient's Insurance Information

All information is encrypted

Please select your primary office location:
Charlotte Hall Office
Waldorf Office

Primary Insurance Information

Salutation:
Salutation:

Primary Insurance Company Address

Primary Insurance Company Address:

Secondary Insurance Company

Salutation:
Salutation:

Secondary Insurance Company Address

Secondary Insurance Company Address:

Assignment and Authorization Agreement

This certifies that I authorize Associates in Radiation Management to apply for benefits for services rendered to me by the above physician/physician group.  I request payments from an insurance or reimbursing agency to be made directly to Associates in Radiation Management/CPRCC (or, in the case of Medicare Part B, benefits to myself or the third party who accepts the assignment). I certify that the information I have provided concerning my insurance coverage is correct. I further authorize the release of any information, including medical information, for this or any related claims to any insurance company or reimbursing agency (or, in the case of Medicare Part B, benefits to the Social Security Administration and Health Care Financing Administration) to determine benefits to which I may be entitled.  Any reimbursing insurance agency or myself may revoke this authorization in writing. I permit a copy of this authorization to be used in place of the original as needed.

Please add a copy of your insurance card's both front and back plus any other insurance documents.

Patient's Insurance Information

All information is encrypted

Please select your primary office location:
Charlotte Hall Office
Waldorf Office

Primary Insurance Information

Salutation:
Salutation:

Primary Insurance Company Address

Primary Insurance Company Address:

Secondary Insurance Company

Salutation:
Salutation:

Secondary Insurance Company Address

Secondary Insurance Company Address:

Assignment and Authorization Agreement

This certifies that I authorize Associates in Radiation Management to apply for benefits for services rendered to me by the above physician/physician group.  I request payments from an insurance or reimbursing agency to be made directly to Associates in Radiation Management/CPRCC (or, in the case of Medicare Part B, benefits to myself or the third party who accepts the assignment). I certify that the information I have provided concerning my insurance coverage is correct. I further authorize the release of any information, including medical information, for this or any related claims to any insurance company or reimbursing agency (or, in the case of Medicare Part B, benefits to the Social Security Administration and Health Care Financing Administration) to determine benefits to which I may be entitled.  Any reimbursing insurance agency or myself may revoke this authorization in writing. I permit a copy of this authorization to be used in place of the original as needed.

Please add a copy of your insurance card's both front and back plus any other insurance documents.

Please note: that you must submit the form to save any information.  Leaving the page will not save any of your insurance information.

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