Assignment of Benefits Agreement for Colorectal Surgery

I, _________________________________ ("Patient"), hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment directly to:

____________________________________ ("Practice/Surgeon")

Authorization Details

Covered Services

This assignment includes all covered medical services provided, including but not limited to:

• Colorectal surgical procedures
• Pre-operative consultations
• Post-operative care
• Follow-up visits
• Related diagnostic services

Financial Responsibility

I understand that:

1. I am financially responsible for all charges not covered by my insurance
2. This assignment will remain in effect until revoked by me in writing
3. A photocopy of this assignment is considered as valid as the original

Insurance Information

• Primary Insurance: _______________________
• Policy Number: _________________________
• Group Number: _________________________

Authorization for Release of Information

I authorize the release of any medical information necessary to:

1. Process insurance claims
2. Determine benefits
3. Secure payment for services rendered

Signatures

Patient Signature: _________________________ Date: __________

Witness Signature: _________________________ Date: __________

This document is legally binding upon execution