Assignment of Benefits Agreement - Cardiac Surgery

Cardiac Surgery Services

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: ________________________

Insurance Information

Primary Insurance: ______________ Policy Number: _________________ Secondary Insurance: ____________ Policy Number: _________________

Authorization and Agreement

I, the undersigned, hereby authorize and direct my insurance carrier(s) to make payment directly to [CARDIAC SURGERY PRACTICE NAME] for surgical services rendered to me or my dependent.

Scope of Authorization

• All major and minor cardiac surgical procedures
• Pre-operative consultations and evaluations
• Post-operative care and follow-up visits
• Related diagnostic procedures
• Hospital-based services

Financial Responsibility

I understand that:

1. I am financially responsible for any charges not covered by my insurance
2. Co-payments and deductibles are due at the time of service
3. This assignment will remain in effect until revoked by me in writing
4. I am responsible for providing current and accurate insurance information

Medicare/Medicaid Certification (if applicable)

I certify that the information provided in applying for payment under Title XVIII or XIX of the Social Security Act is correct.

Signatures

Patient/Guardian Signature: _________________ Date: ______________

Witness Signature: _________________________ Date: ______________

Practice Information

[PRACTICE NAME] [ADDRESS] [PHONE/FAX] [LICENSE/CERTIFICATION NUMBERS]