1.05 – General – Ophtho

1.05 - General - Ophtho

By Dr. Alexander Mantas|2015-04-21T04:36:07+00:00April 21st, 2015|0 Comments

About the Author: Dr. Alexander Mantas

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Prior GI Work Up

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If Yes, please briefly describe your work up including all previous procedures and their dates and the gastroenterologist who treated you.

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I understand that if any of the insurance information I have provided is incorrect or if I fail to notify the office of any insurance changes that I am responsible for all physician charges and non-covered medical services.

I hereby authorize the release of any medical information necessary for the process of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Alexander Mantas, MD, PA, Digestive Health Associates of Texas, PA and Digestive Health Management Endoscopy Centers. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as an original. I have received the Notice of Privacy Practices.

By Submitting This Form, Patient Agrees To All Terms, Conditions & Disclaimers!

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1.05 – General – Ophtho