Assignment of Benefits Agreement for Plastic Surgery Services

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Insurance Information

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

Assignment of Benefits Authorization

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above-named insurance company(ies) and assign directly to Dr. _________________ all insurance benefits, if any, otherwise payable to me for services rendered.

Terms and Conditions

1. Financial Responsibility

   • I understand that I am financially responsible for all charges whether or not paid by insurance
   • I agree to pay all co-payments, deductibles, and non-covered services
   • I understand that cosmetic procedures are not covered by insurance

2. Authorization for Release of Information

   • I authorize the release of any medical information necessary to process insurance claims
   • I authorize the release of treatment records to other healthcare providers as needed

3. Payment Terms

   • Payment is due at the time of service unless prior arrangements have been made
   • A photocopy of this assignment is considered as valid as the original

Acknowledgment

I have read and understand the above assignment of benefits agreement.

Patient/Guardian Signature: _________________ Date: __________

Print Name: ______________________________

Witness: ________________________________ Date: __________