Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 • www.DesertPerinatalAssociates.com
Patient Name:
Patient Signature Date
DOB:
DESIGNATION OF AN AUTHORIZED REPRESENTATIVE
An Authorized Representative is a person you authorize to act on your behalf, in the filing or
pursuance of claims and the filing or pursuance of appeals of denied claims. This authorization
is granted for any present or future claims for health care benefits you may have.
• I understand that as a result of authorization, my insurance company may disclose and
release information concerning benefit eligibility, claims status, claims approval or
claims denial reasons in connection with the above referenced health care claims to
the individual names above.
• I understand my health information may include but not limited to medical, pharmacy,
dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive,
communicable disease and health care program information.
• I understand that this authorization is voluntary.
• I understand this designation is subject to revocation at any time except to the extent
that my insurance has taken action in reliance on this designation before they knew of
the revocation.
By signing this form, you appoint Desert Perinatal Associates as your Authorized
Representative.
click to sign
signature
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