Acknowledgement and Authorization:
I have read, understand and agree to abide by the above payment policy. I understand that charges not covered by my insurance company, as well as copayment, deductibles and coinsurance, are my responsibility.
I authorize my insurance benefits to be paid directly to: Michael T. Lin, M.D.
One-Time Authorization For Medicare recipients:
I request that my payment of authorized Medicare benefits be made to me on my behalf to Michael T Lin MD, Inc for any services furnished me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. Additionally, I request that payment of authorized Medi-gap benefits be made to either me or on my behalf to Michael T. Lin MD., Inc. for any services furnished by this provider. I authorize any benefits or the benefits payable for related services.