Med. Insurance Coverage


LANG FAMILY MEDICINE DOES NOT FILE ANY INSURANCE, INCLUDING MEDICARE.

Although we do not file medical insurance or Medicare, we still work closely with pharmacies, outside labs, and imaging clinics that may take your coverage. 

PLEASE CHECK ONE:

 

IF YOU CHECK THIS BOX, PLEASE PROCEED TO FILL OUT THE FORM BELOW.

We may need to send you outside of our clinic for various testing, labs, x-rays or other types of imaging.  We may also need to provide referrals to other medical offices or pharmacies on your behalf.

In order to do this efficiently and as quickly as possible, we may need to give the name of your insurance company to any of the above mentioned entities.  If applicable, please provide us with the following information:

Patient name: Date:

Patient Insurance Company name:

Do you have prescription coverage?

We have accounts with Quest and LabCorp.  Which lab does your insurance company prefer?

 

Other

If your medical insurance changes at any time, please let us know so that we can let you update your insurance information.

PLEASE NOTE: BY SIGNING THIS DOCUMENT YOU AGREE THAT YOU ARE RESPONSIBLE FOR ALL CHARGES INCURRED BY SERVICES RENDERED.

Leave this empty:

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Signature Certificate
Document name: Med. Insurance Coverage
lock iconUnique Document ID: ec0d8503ca70c391364501dcca4ea920c0aff0ca
Timestamp Audit
May 25, 2021 9:56 pm CSTMed. Insurance Coverage Uploaded by Derek Lang - langnewpatient@gmail.com IP 174.108.1.127