Primary Insurance:

Phone #:

Subscriber ID:

Group #:

Subscriber Name:

Subscriber SS#:

Subscriber Date of Birth:

Secondary Insurance:

Phone #:

Subscriber ID:

Group #:

Subscriber Name:

Subscriber SS#:

Subscriber Date of Birth:

Employer Name:

Phone #:

Employer Address:

City:

State:

Zip:

I request the services of:  Dr. Bernard Goldstein, P.A., duly licensed physician in the State of Florida, and all personnel, the consent to examination, diagnostic procedures and treatment which may need to be performed on my behalf.  Also, I authorize the release of any medical information, to any person or corporation, necessary to process my claim.

I hereby authorize direct payment for all valid insurance benefits including all major medical benefits, be made on my behalf to:  Dr. Bernard Goldstein, P.A.  I understand I will be financially and legally responsible for any charge(s) not covered by assignment.

I certify that I have read the above authorizations and understand and agree to same, and also certify no guarantee or assurances have been made as to the results that may be obtained.