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Authorization to Bill Insurances and Patient Agreement - Mark Latina

Authorization to Bill Insurances and Patient Agreement

Mark A. Latina, M.D. & Vicki Kvedar,M.D.

Advanced Glaucoma Specialists

Welcome to our practice, This agreement allows us to bill your insurance company for the medically covered services that we provide and outlines additional fees that may be charged. As a patient of Advanced Glaucoma Specialists, I understand it is my obligation and responsibility to know if my insurance plan requires a referral, and or, authorization for services rendered.

Please download PDF file, see below under Related Files

Related Files

Authorization.02.15.2015

Contact Us

Business Hours

Main Office

Pediatric and Comprehensive Eye Exam Office