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 & 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 #.

Yes, I have recieved my HIPAA notice, Medicare Supplier Standards, Patient's Rights & Responsibilites, and Benefit Authorization