Medical Authorization
I request that payment of authorized Medicare benefits be made
on my behalf to Optometric Physicians of Middle Tennessee for
services furnished me by Optometric Physicians of Middle
Tennessee. I authorize any holder of medical information about me
to release to the Division of Medicare and Medicaid Services and its
agents any information needed to determine those benefits payable for
related services. I understand my signature requests that payment
be made and authorizes release of medical information necessary
to pay the claim. If “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 physician or supplier agrees to accept
the charge determination of the Medicare carrier as the full charge,
and non-covered services. Coinsurance and deductible are based
upon the charge determination of the Medicare carrier.