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Insurance Verification

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Fill out this form after you have scheduled your consultation with our office so we can verify your benefits before you come in for your appointment:

Your Information


Insurance Information



I, the undersigned, certify that I have insurance coverage and authorize Dr. Richard R Moy to have all claims processed on my behalf under the insurance benefit plan level, either PPO or Out-of-Network. I, certify that I (or my dependent) have insurance coverage with the aforementioned provider and assign directly to Dr. Moy all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I understand that I financially responsible for any co-payment, co-insurance, deductible and other charges whether or not paid by insurance.