Assignment of Benefits Agreement for Concierge Medical Services

Patient Information

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

Agreement Terms

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 NAME] [ADDRESS] [PHONE/FAX]

Authorization Statements

1. I authorize the release of any medical information necessary to process insurance claims related to my medical care.

2. I understand that this Assignment of Benefits relates to all services provided by [PRACTICE NAME], including but not limited to:

   • Annual comprehensive physical examinations
   • 24/7 physician availability
   • Same-day or next-day appointments
   • Extended office visits
   • Preventive care services

3. I understand that I remain personally responsible for:

   • Annual concierge membership fees
   • Any deductibles
   • Co-payments
   • Co-insurance amounts
   • Non-covered services

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

Acknowledgment

I have read and understand this Assignment of Benefits agreement.

Patient Signature: _________________ Date: _________________

Witness: _________________________ Date: _________________

Practice Acknowledgment

Accepted by: _____________________ Date: _________________ Authorized Representative of [PRACTICE NAME]

This document is not a substitute for legal advice and should be reviewed by legal counsel.