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Authority to collect information is in sections 205 A 1872 and 1875 of the Social Security Act as amended and 44 USC 3101 41 CPR 101 ET SEQ And 10 USC 1079 and 1086 5 USC 8101 ET SEQ And 30 USC 901 RT SEQ. determine your eligibility. Printed patient name Patient DOB Patient/Guardian Signature AUTHORIZATION FORM Notice to patient regarding collection from insurance companies We are authorized by HCFA Champus and OWCP to ask you for insurance information needed in the administration of the...
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