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PATIENT AUTHORIZATIONS
INSURANCE RELEASE AND AUTHORIZATION
Patient's Name:
I authorize Dr. Lygas and/or Dr. Pellegrino to release to my insurance company and its agents any information needed to determine the benefits payable for medical services.

I authorize the payment to benefits to be made in my behalf directly to: "Theodore B. Lygas, M.D." or "John M. Pellegrino, M.D." for any covered services furnished me by Dr.Lygas / Dr.Pellegrino. I understand that I am responsible for any deductibles, copayments, coinsurance, or non-covered expenses that my policy does not cover.

I authorize Theodore B. Lygas M.D., P.A. and its employees to appeal insurance decision on my behalf. I consent to insurance releasing information about my claims and/or appeals to Theodore B. Lygas, M.D.,P.A, and its employees.

I authorize the release of medical record information for treatment, payment, or health care operations. I permit a copy of this authorization to be used in place of the original.
Dated: Saturday, February 17, 2018
 
PATIENT’S MEDICARE AUTHORIZATION
Patient's Name:
Medicare #:
I request that payment of authorized Medicare benefits be made either to me or on my behalf to: "Theodore B. Lygas, M.D." or "John M. Pellegrino, M.D." for any services furnished me by that physician/clinic/supplier. I authorize any holder of hospital or medical information about me to release to Health Care Financing Administration and its agents any information needed to determine the benefits payable for related services.

I request that payment of authorized Medigap benefits be made either to me or my behalf to Theodore B. Lygas, M.D. or John M. Pellegrino, M.D. for any services furnished to be by that physician/supplier. I authorize any information needed to determine these benefits payable for related services.

I authorize Theodore B. Lygas M.D. , P.A. , and its employees to appeal Medicare decisions on my behalf. I consent to Medicare releasing information about my claims and/or appeals to Theodore B. Lygas, M.D.P.A. , and its employees.

I authorize the release of medical records information for treatment, payment, health care operations. I permit a copy of this authorization to be used in place of the original.
Dated: Saturday, February 17, 2018
 
 

Call 732-458-4600 for appointments and more information.
Patients from Monmouth County or Ocean County and want an appointment with Dr. Lygas or Dr. Pellegrino
Patients from Brick, Bricktown, Brielle, Wall, Manasquan, Spring Lake, Avon, Avon by the Sea, Long Branch, Sea Girt, Neptune Township, Bradley Beach, Belmar, Lake Como, spring Lake Heights, Neptune, Farmingdale, Ocean Township, Point Pleasant, Point Pleasant Beach, Howell, Bayhead, Mantoloking, Seaside Park, Lakewood, or in Ocean County, NJ, call 732-458-4600 for a Brick Office appointment with Dr. Theodore Lygas or Dr. John Pellegrino.

Patients from Toms River, Forked River, Manahawkin, Long Beach Island, Berkeley Township, Bayville, Beach Haven, Ocean, Manchester, Whiting or any of the Senior Villages, call 732-458-4600 for a Toms River or Barnegat office appointment with Dr. Lygas or Dr. Pellegrino.

Patients from Freehold, Freehold Township, Upper Freehold, Marlboro, Manalapan, Colts Neck, Howell, Eatontown, Jackson, Plainsboro, Monroe, Old Bridge, or Englishtown, call 732-458-4600 for a Freehold or Brick office appointment with Dr. Lygas or Dr. Pellegrino.

Monmouth County patients can be seen in the Brick or Freehold office. Ocean County patients can be seen in the Brick, Toms River, or Barnegat office.

Zip Codes we service: 07722, 07731, 07735, 07717, 07719, 07727, 07740, 07753, 07754,
07762, 07799, 07801, 07802, 07803, 07806, 07869, 08008, 08015, 08527, 08721, 08722,
08723, 08724, 08730, 08731, 08732, 08736, 08740, 08741, 08742, 08750, 08751, 08752,
08753, 08754, 08755, 08756, 08757 and any surrounding towns.