California Clinic for Anxiety Disorders Annie Zadori, Psy.D License number: PSY 32733 Insurance VerificationThis is to authorize Annie Zadori, Psy.D (PSY 32733) to release any and all medical information to my insurance carrier for purposes of insurance verification, claims administered and evaluation, utilization review, and financial audit. This authorization remains in effect from date of signing until revoked in writing.Patient First Name: First Middle Name: First Last Name: First Patient DOB: MM slash DD slash YYYY Patient Address: City: Zip Code: Insurance Company Name: Insurance Type: PPO HMO Insurance Member ID number: Insurance Group ID: Insurance Claims Phone Number:Insurance Subscriber’s Name: First Relationship od Subscriber to Insured: First Patient or Financial Responsible Parent/Spouse Signature:Date: MM slash DD slash YYYY CONFIDENTIALITY NOTICEThe documents including and/or accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for return of these documents.
