Back & Neck Pain CenterVidalia & Baxley, GA

Insurance Questionnaire

Complete this form so that we may properly file your insurance for you.

Please note: This form will not be submitted via the Internet, so security is not an issue. Print it, sign it and bring it with you to your first appointment.

The following questions are necessary so that we may properly file your insurance for you. These questions are taken directly from the insurance form that we must fill out and file for you. Please answer as fully as possible.

Patient's or Authorized Person's Signature: I authorize the release of any medical or other information necessary to process my insurance claim. This is to serve as a long-term authorization card.

Signed: __________________________________     Date: _________________

Insured's or Authorized Person's Signature: I authorize payment of medical benefits to Back & Neck Pain Center for the services described on the insurance form. This authorization is to apply to all occasions of service until it is revoked in writing. I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office.

Signed: __________________________________     Date: _________________

Medicare Only

All doctors have been instructed to ask the following questions of all Medicare patients.