TOWN 'N COUNTRY PODIATRY CENTER

FOOT CARE CENTER OF TAMPA  P.A.

7926 West Hillsborough Avenue, Suite G

1020 West Hillsborough Avenue

Tampa, Florida   33615

Tampa, Florida   33603

I understand that Dr. Barry C. Blass' office will be filling my insurance claims by means of computer generated forms.

I authorize the release of any medical information necessary to process my insurance claims.  I also
request payment of government benefits either to myself or to the party who accepts assignment below.

Signed:

Date:

In the event that I do not pay for my treatment in full, I authorize payment of medical benefits to Dr. Blass.

Name of Beneficiary:

I request that payment of authorized Medigap benefits be made on my behalf to Barry C. Blass, D.P.M. for any services furnished me by Dr. Blass.  I authorize any holder of medical information about me to release to

(supp insurer) any information needed to determine

these benefits or the benefits payable for related services.  I understand that I do not need to provide my supplemental insurer with information concerning this Medicare claim, because my signing this authorization will cause Medicare payment information to cross over automatically.

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices.

Patient Name (please print)

Date

Parent, Guardian or Patient's legal representative

Signature:

X