I understand that Pro-Fit requires my signature for an outstanding claim. By providing my digital signature/approval below, I am requesting that my claim be filed with my insurance provided.
Name of the Patient (first & last):
Account Number (found under your address):
Supplier Standards
Rights & Responsibilities
If you have any questions regarding your benefits for this claim, please feel free
If you have any questions regarding your benefits for this claim, please feel free Benefit Authorization to contact our billing department at 205-326-0050 and reference your account #.
to contact our billing department at 205-326-0050 and reference your account #.
