Appeals Authorization

APPEALS AUTHORIZATION

I,
Patient/Guardian Name
(patient/guardian), grant AxioBionics, LLC authorization from this day forward to represent me in the appeals process with my insurance company or any third-party entity for any denial received for AxioBionics products and services.
Authorized Representative (print)
Date
MM slash DD slash YYYY
Patient Name (print)
First Middle Last
Date
MM slash DD slash YYYY
Address
Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone

APPEALS AUTHORIZATION