Center for Plastic Surgery
Dell P Smith, M.D.
1880 Fillmore Street
Twin Falls, ID 83301
(208)735-8386   Fax (208)735-0434
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I authorize other health care providers to release my medical records to Dell P Smith, M.D. I authorize the 
release of medical information to Medicare/Medigap/ Other Third Party Payors. I authorize evaluation and
treatment by Dell Smith M.D. I authorize payment of medical benefits to Dell Smith, M.D. I permit a copy of 
this authorization to be used in place of the original. I request that payment of authorized Medicare/
Medigap benefits be made either to me or on my behalf of Dell Smith, M.D., for any services furnished me by 
that physician. I authorize any holder of medical information about me to release it to Health Care Financing
Administration/Medigap and its agents, any information needed to determine these benefits or the benefits
payable for related services We are not contracted with Humana and Blue Cross Secure Blue PPO
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