Please attach a copy of your state picture identification AND a copy of your insurance card here. If not,
please attach under the messaging tab in the Patient Ally Portal, via our secure email address at: info@ufirsthealthcare.org OR attach under the Book Appointment tab on our web site at :www.ufirsthealthcare.org for any difficulties, please call our office: 833-583-4778.
INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am responsible for all charges ncurred by me and all charges not allowed by my insurance company. I authorize the release of medical information necessary to process my claims. I authorize payment of any assigned medical benefits to my provider directly.
