Medicare Assignment on File

I request that payment of authorized Medicare benefits be made on my behalf to Dr. Bruce D. Levine, D.P.M., for any services furnished me by the listed provider/supplier. I authorize any holder of medical information about me to released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. I "other health insurance" is indicated in item 9 of the HCFA _ 1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

__________________________________________________________________ (Patients Name - Please Print)

__________________________________________________________________ (Patients Signature)

__________________________________________________________________ (Patients Medicare No.)

__________________________________________________________________ Date)

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