Assignment of Benefits Authorization Form

Patient Information

Name: _______________________________ Date of Birth: //___ Address: _____________________________ Phone: ________________ Medicare/Insurance ID: _________________

Authorization Statement

I, the undersigned, authorize direct payment of medical benefits to [PRACTICE NAME] for services rendered by the provider and their staff. I understand that I am financially responsible for any balance not covered by my insurance carrier(s).

Insurance Benefits Assignment

• I authorize the release of any medical information necessary to process insurance claims
• I permit a copy of this authorization to be used in place of the original
• I understand this assignment will remain in effect until revoked by me in writing
• I acknowledge that my insurance coverage is subject to:
  • Deductibles
  • Co-payments
  • Coverage limitations

Medicare Authorization (if applicable)

I request that payment of authorized Medicare benefits be made on my behalf to [PRACTICE NAME] for any services furnished to me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits.

Signatures

Patient Signature: ____________________ Date: //___

If signed by representative: Representative Name: _________________ Relationship: ____________ Representative Signature: _____________ Date: //___

Witness

Witness Name: _______________________ Date: //___ Witness Signature: ___________________

This authorization is valid for all episodes of care rendered by [PRACTICE NAME] until revoked.