This document allows Lingraphica to act as a representative on behalf of the client in the event of a denial from an insurance company/payor. The client is required to fill out Name of Party, Beneficiary Number, and the first section. Signature of Patient should be signed under the box Signature of Party Seeking Representation. QuickSubmit is a partial form. View the form in its entirety by downloading it. Fill out your section by using the QuickSubmit option.
