Lakeside Neurology, P.C.
Notice & Acknowledgement (Please Print)

I acknowledge that I have received the attached Notice of Privacy for Lakeside Neurology, P.C.,
(formerly Rim & Sul, M.D., P.C.)

Printed Name of Patient____________________________________________________________

(Signature of Patient or Personal Representative)                                                   

If personal representative’s signature appears above, describe personal representative’s relationship
to the patient:_____________________________________________________________________

Authorization to pay benefits to physician: I hereby authorize payment directly to the undersigned
physician or the surgical and or medical benefits, if any otherwise payable to me for his services
and described below but not to exceed the reasonable and customary charges for those services.


Authorization to release information: I hereby authorize the undersigned physician to release any
information acquired in the course of my examination or treatment.


Medicare Part B
One time authorization agreement statement to permit payment of Medicare benefits to providers,
physicians and patient.

Name of Beneficiary__________________________________ Medicare Number______________

I request that payment of authorized Medicare benefits be made either to me on behalf for any
services furnished me by this provider. I authorize any holder of medical or other information about
me to release to the Health Care Financing Administration and its agents any information needed to
determine these benefits for related services.

______________________Payment to Provider.         ______________________Payment to Patient

X______________________________________________________ Date______________________
Patient Signature                                                                  
X______________________________________________________ Date______________________
Provider Signature                                                                

For services furnished to inpatients of a hospital or SNF, this request is effective for the period of
confinement. For services furnished by a provider/supplier or on an outpatient basis, this request
is effective until revoked by the beneficiary.