Patient's Insurance Authorization

I hereby authorize the processing of the medical insurance either by electronic or manual method by the listed provider. My signature authorizes payment for all major medical and/or surgical benefits to which I am entitled from the listed insurer to pay to the listed provider assignee. I further information necessary to secure the payments(s). I recognize my financial obligation of any co-insurance or deductible, and non-covered services that may be required. This agreement will remain in effect until revoked by me in writing. A photocopy of this document is to be considered as valid as an original.

__________________________________________________________________ (Patients Name - Please Print)

__________________________________________________________________ (Patients Signature)

__________________________________________________________________ (Insurance Company Name)

__________________________________________________________________ (Patients Group Policy I.D.)

__________________________________________________________________ (Patients Insurance Policy Number)

Bruce D. Levine, D.P.M. 1360 West Sixth Street Suite 150, West Building San Pedro, CA. 90732 (310) 548-1191