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):
Rights & ResponsibilitiesIf 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 #.