Professionals in the field of Endocrine, Diabetes, and Metabolism.
* = Required
I understand that physician phone calls are telehealth visits and that online patient portal messages requiring physician input are billable services.
I authorize Maryland Endocrine, P.A. to apply for benefits on my behalf for covered services rendered.
I certify that the information I have reported with regard to my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claim to my insurance carrier. (Or in the case of Medical Part B benefits to Social Security Administration and Health Care Financing Administration).
I authorize payment of medical insurance benefits which are payable to me under the terms of my insurance to be paid directly to Maryland Endocrine, P.A. for services rendered. I further authorize the use of any information needed for processing my insurance claims. A copy of this authorization may be used in place of the original.
This authorization may be revoked either by me or my insurance carrier at any time in writing. I understand and agree that I am financially responsible for charges not paid by my insurance company.
I allow MARYLAND ENDOCRINE, P.A. to release any information relevant to my care to:
(Parents, grandparents, siblings, children)
select if you currently have problems with
Include your over-the-counter medications as well as any diabetes supplies. For insulin, include whether pen or vial and the concentration (U-100, U-200, U-300, U-500).
I, ______, BORN ______ HEREBY AUTHORIZE ______ TO RELEASE TO: Maryland Endocrine, Columbia M.D., 21044. F# 301-953-3543
Any information from the diagnosis and records of any treatment or examination rendered to me during the period from ______ to ______.
I understand that this authorization shall be effective for a period of one year unless otherwise noted. I understand that I may cancel this requst with written notification but that it will not affect andy information released prior to notification of cancellation. I understand that the information used may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this is authorized if furnished may not condition its treatment of me on whether or not I sign the authorization.
All requests for chart copies may be charged at the rates established acceptable by Maryland State law.
By signing and submitting this form, I certify that the information provided through this form is accurate to the best of my knowledge.
HealthCare Support Portal facilitates better communication with your physician's office by providing convenient access during business hours from the comfort and privacy of your own home or office.
If you like to keep up-to-date with MD Endocrine, please sign-up for our email updates.