<p> LIFETIME BENEFICIARY CLAIM AUTHORIZATION (“SIGNATURE ON FILE”)</p><p>______NAME OF PATIENT MEDICARE ID NUMBER</p><p>I request that payment of authorized Medicare benefits be made on my behalf to Edward Ayub M.S., PT. For any services furnished to me by that physician/supplier. I authorize any holder of medical information to release to Health Care Financing Administration (HCFA) and its agents any information needed to determine these benefits payable for related services.</p><p>I understand my signature requests the payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes release of the information to the insurance or supplier, which agrees to accept the charge determination of the Medicare carrier as the full charge, and non-covered services. Co- insurance and the deductible are based upon the charge determination of the Medicare carrier. ANNUAL MEDICARE CAPITATION FOR PHYSICAL THERAPY</p><p>EFFECTIVE JANUARY 1, 2011 Medicare has implemented a capitation of $1,870.00, which is to be shared between physical therapy and speech therapy. Medicare will pay $1496.00, (80% of the cap) and the patient will be responsible for $374.00 (20% of the cap). If you have a supplemental or secondary insurance, they should cover the 20% of the cap. Please note, this $1,860.00 capitation, which Medicare is implementing, is based on an annual basis and is per patient regardless of the number of diagnosis and/or the severity of the condition.</p><p>______PATIENT SIGNATURE DATE</p><p>D:\Docs\2017-07-19\05821649aa5fda01c81e4a782a49fc20.doc</p>