BILLING INFORMATION MUST BE COMPLETED
KEY: S - SERUM B - BLUE L - LAVENDER R - RED Y - YELLOW U - URINE G -
GRAY R - PLAIN RED T - TIGER TOP
MEDICARE ADVANCE BENIFICIARY NOTICE (ABN)
I authorize the release of medical information necessary to process this
claim and request payment of benefits to the party who accepts assignment.
I permit the copy of this authorization to be used in place of the original.
I understand that medicare is likely to deny payment for certain procedures.
I agree to be personally responsible for payment of laboratory services
if Medicare does not provide payment.