36C25618R0495-019.pdf
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T hi s in fo rm at io n is co ll ec te d u nd er th e au th o ri ty o f T it le
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In ac co rd an ce w it h se ct io n o f th e P ap er w or k R ed u ct io n A ct o f
5, w e m ay n ot co nd uc t or sp on so r, an d y ou ar e n ot re q ui re d to re sp on d to a co ll ec ti on o f in fo rm at io n u nl es s it d is pl ay s a v al id O
M B n um b er
W e an ti ci pa te th at th e ti m e ex pe nd ed b y al l in d iv id ua ls w h o m u st co m p le te th is in v oi ce w il l av er ag e m in ut es
T hi s in cl ud es th e ti m e it w il l ta k e to re ad in st ru ct io n s, g at he r th e n ec es sa ry fa ct s an d fi ll o ut th e fo rm
T he p ur po se o f th is fo rm is to au th o ri ze m ed ic al tr ea tm en t an d p ro vi d e a m ea ns to b il l fo r th is se rv ic e al th ou gh p ri v at e p ro vi d er s m ay al so u se lo ca l b il li ng fo rm s o r U
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S ub m is si o n o f th is fo rm is v ol un ta ry an d fa il ur e to re sp on d w il l h av e n o im p ac t o n b en ef it s to w h ic h y ou m ay b e en ti tl ed
C o m m en ts re g ar d in g th is b ur de n es ti m at e o r an y o th er as p ec t o f th is co ll ec ti on ,i n cl ud in g su g ge st io ns fo r re du ci ng th e bu rd en m ay be ad dr es se d by ca ll in g th e
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A cc ep ta nc e o f th is au th o ri za ti o n to re nd er se rv ic e is go v er n ed by th e fo ll o w in g
F ee s o r ra te s li st ed re p re se nt m ax im u m al lo w an ce fo r se rv ic es sp ec if ie d
In n o ev en t sh ou ld ch ar g es b e m ad e to th e V
A in ex ce ss of u su al an d cu st om ar y ch ar g es to th e ge n er al p ub li c fo r si m il ar se rv ic es
P ay m en t b y V
A is pa ym en t in fu ll fo r au th o ri ze d se rv ic es re n de re d.
U n le ss ot h er w is e ap p ro v ed b y V
A se rv ic es ar e li m it ed in ty p e an d ex te nt to th o se sh ow n o n th e au th or iz at io n.
If se rv ic es ar e n ot in it ia te d fo r an y re as on
,r et u rn a co py of th e au th o ri za ti on to th e is su in g o ff ic e w it h a b ri ef ex p la n at io n
A co py o f th e O p er at iv e R ep o rt w il l be fo rw ar d ed to th e au th o ri zi n g fa ci li ty w it h in w ee k fo ll o w in g an y m aj o r su rg er y.
A co py o f th e h os p it al su m m ar y w il l be fo rw ar d ed to th e au th or iz in g fa ci li ty w it h in w or k d ay s fo ll ow in g th e re le as e o f th e pa ti en t fr om th e ho sp it al
A ll q u e s ti o n s re la ti n g to th is a u th o ri z a ti o n s h o u ld b e re fe rr e d to th e is s u in g
V A
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