Assignment of Benefits Agreement - General Surgery

[Practice Name]

Address: [Street Address] City, State ZIP Phone: [Phone Number]

I, _________________________________ (print patient name), hereby assign and transfer all medical and/or surgical benefits, including major medical benefits to which I am entitled, private insurance, and any other health plans to [Practice Name].

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

Authorization

I understand and agree to the following:

1. I am financially responsible for all charges whether or not paid by my insurance carrier
2. I hereby authorize [Practice Name] to release all information necessary to secure payment
3. This authorization applies to all surgical procedures and related services provided by [Practice Name]
4. I authorize the use of this signature for all insurance submissions
5. I understand that this assignment does not guarantee full coverage of my medical expenses

Medicare Authorization (if applicable)

I request that payment of authorized Medicare benefits be made either to me or on my behalf to [Practice Name] for any services furnished to me by that provider.

Patient Signature: _________________________________ Date: _______________

Witness Signature: _________________________________ Date: _______________

Guardian Signature: ________________________________ Date: _______________ (If patient is a minor or legally incapacitated)

OFFICE USE ONLY

Received by: _____________________ Date: _______________ Patient ID: _____________________ Insurance Verification: □ Complete □ Incomplete