Name *(Required) E-mail *(Required) MEDICARE BENEFITS AUTHORIZATION I request that payment of authorized Medicare benefits be made either to me or on my behalf to HealthQuest for services furnished to me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits payable for related services. Patient Date (mm/dd/yyyy) Enter Code Verification Code
