Assignment of Benefits Agreement

Patient Information

Name: ________________________________ Date of Birth: _________________________ Account Number: _______________________

Authorization Statement

I, the undersigned, authorize direct payment of medical benefits to [Practice Name] for services rendered by the physician(s) and/or their staff. I understand that I am financially responsible for any charges not covered by my insurance carrier.

Terms and Conditions

1. I hereby assign all medical and/or surgical benefits, including major medical benefits to which I am entitled, private insurance, and any other health plan to [Practice Name].

2. This assignment will remain in effect until revoked by me in writing.

3. A photocopy of this assignment is to be considered as valid as the original.

4. I understand that I am financially responsible for all charges, whether or not paid by said insurance.

5. I hereby authorize said assignee to release all information necessary to secure payment.

Signature Section

Patient Signature: _____________________ Date: ________________________________

If signed by person other than patient: Name: ________________________________ Relationship to Patient: ________________

Practice Information

[Practice Name] [Address] [Phone Number] [Tax ID/NPI]

This form must be completed before services can be rendered