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:
I DO NOT HAVE MEDICAL INSURANCE THAT I CAN FILE
I HAVE MEDICAL INSURANCE COVERAGE THAT I CAN FILE.
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? YesNo
We have accounts with Quest and LabCorp. Which lab does your insurance company prefer?
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:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Med. Insurance Coverage
Agree & Sign