Insurance Information

Primary

Secondary

Name of Insurance Company

Primary Name of Insurance Company

Secondary Name of Insurance Company

Policy Number

Primary Policy Number

Secondary Policy Number

Group Name

Primary Group Name

Secondary Group Name

Group Number

Primary Group Number

Secondary Group Number

Name of Insured

Primary Name of Insured

Secondary Name of Insured

Insured Date of Birth

Primary Insured Date of Birth

Secondary Insured Date of Birth

Insured Social Security Number

Primary Insured Social Security Number

Secondary Insured Social Security Number

Employer of Insured

Primary Employer of Insured

Secondary Employer of Insured

Please Read Carefully:

Lonestar Foot & Ankle Care will apply for patient insurance benefits. The patient is responsible for ALL fees, regardless of Insurance Coverage. All charges are due at time of service.

I understand that I am responsible for any amount NOT covered by insurance. I hereby authorize payment directly to Lonestar Foot & Ankle all insurance benefits not to exceed the regular charges. I hereby authorize Lonestar Foot & Ankle to release the information needed to any physician and/or third party responsible for payment of such services.

Patients Signature or Legal Guardian

Date

Staff Signature

PAYMENT METHODS

Our commitment is to your optimal well-being. In order to make it as easy and convenient as possible for you, we offer a variety of payment methods including:

Insurance Information