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 other healthcare providers at this practice. I understand that I am financially responsible for any charges not covered by my health insurance plan.

Terms and Conditions

1. I hereby assign all medical benefits, including major medical benefits to which I am entitled, private insurance, and any other health plans to [PRACTICE NAME].

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

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

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

5. If my insurance plan requires a referral or authorization, I understand that it is my responsibility to obtain it.

Medicare/Medicaid Certification (if applicable)

I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

Acknowledgment

Signature of Patient/Guardian: _____________________ Date: ________________

Print Name: __________________________________ Relationship to Patient (if not self): _______________

Practice Information

[PRACTICE NAME] [ADDRESS] [PHONE] [FAX] [EMAIL]

Form ID: AOB-IM-[DATE]