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Medical Arts Press® Insurance Assignment Release Pad

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Item # 174-24223

$3.00
per Pad
When you buy 40+

Pad

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1 PAD = 1 HUNDREDS

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Description Specifications

Pad size: 4x5-1/2" 5 pads per pack.

Form specifies patient insurance coverage and authorizes assignment of payment to your practice. States patient accepts responsibility for charges. Authorizes use of signature on insurance submissions and release of health care information to designated insurance carriers. Personalization includes your name, address and phone number.

Product Information: Form Type :

Insurance; Format :

Medical Authorization Form; Sheet Size :

4" x 5-1/2"; Form Size :

4" x 5-1/2"; Media Quantity :

500; Binding Type :

Padded; Paper Color :

White; Number of Parts :

1; Carbonless :

No; # Up Per Sheet/Page :

1; NCR Paper :

No; Numbered :

No; Holes Punched :

None; Personalization :

No; Security Features :

No
Miscellaneous: Brand Name :

Medical Arts Press; Country of Origin :

USA
Weight: Weight :

0.32 lbs. per Pad

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