Consent for Claims Submission

Tolga Taneli, MD LLC
126 Washington St Ste 1
Morristown NJ 07960
tel: 973-944-0844 fax: 973-934-4344
Consent for Medical Claims Submission
I understand I am solely responsible for payment at the time of service. As a courtesy, Tolga Taneli, MD will submit medical claims on my behalf. I understand that my health insurance provider may or may not cover a portion of payment for services.
Do you authorize release of medical information sufficient to submit a claim?

I authorize the release of any medical or other information as necessary to process claims. (If you don't consent, claims cannot be submitted on your behalf.)
Do you authorize payment of medical benefits directly to Tolga Taneli, MD? (If you don’t consent, you will directly receive any payments made by the insurance. You will be responsible for the invoiced amount.)

I authorize payment of medical benefits directly to Tolga Taneli, MD. I understand that Dr. Taneli is not an in-network provider and I am responsible for the difference between the invoiced amount and insurance-covered portion of each claim.
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Consent for Medical Claims Submission