First-Call Medical, Inc. - Nationwide 24-Hour Holter, Event, and Pacemaker Monitoring


Secure Patient Authorization Form

Monitor Information:*
Holter Monitor In-Home Service Request
Looping Cardiac Event Monitor Monitor Applied in Office
Non-Looping Cardiac Event Monitor   Monitor Serial #:
Blood Pressure Monitor
Mobile Cardiac Telemetry
Wireless Cardiac Event Monitor

Patient Information:
Last Name:* First:* MR#:*
Email Address: Sex: Male   Female D.O.B.*
Address: City: State:   Zip:
Home Phone:* Work: Cell:

Primary Insurance Information:
Company: Attention:
Address: City: State:   Zip:
Phone: Website:
Policy/Group #: Identification #:
Subscriber Name: Subscriber's Social Security #:
Relationship of Patient to the Subscriber: Self   Spouse   Child  

Secondary Insurance Information:
Company: Attention:
Address: City: State:   Zip:
Phone: Website:
Policy/Group #: Identification #:
Subscriber Name: Subscriber's Social Security #:
Relationship of Patient to the Subscriber: Self   Spouse   Child  

Diagnosis and/or Indications for Test:    
 

Physician Or Account Information:
Physician Last Name:* Physician First Name:*
Practice Name:* Email:
NPI Number: Physician E-Signature:
Address: City: State:   Zip:
Phone:* Fax:

Patient Authorization Statement:
I authorize any holder of medical or other information about me to release to the carrier(s) listed above any information needed to process this claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits for technical component cardiac service to First-Call Medical, Inc., which accepts assignment on this claim. I acknowledge that any services not covered by my insurance will be my responsibility. I also acknowledge responsibility for the assigned monitor to be returned in proper working order upon completion of service. Failure to do so will result in a charge billed directly to me to cover the replacement costs of the monitor. I have read the Notice of Privacy Practices and Patient Authorization for Disclosure of Protected Health Information materials.
Patient E-Signature: Date:

First Call Medical, Inc.
Nationwide 24-Hour Holter, Event, and Pacemaker Monitoring
28 Andover St. Suite 200, Andover, MA 01810
800 274 5399
info@fcminc.com

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