Assignment of Benefits Authorization Form - Vascular Surgery

Patient Information

Name: _________________________________ Date of Birth: //___ Address: _______________________________ Phone: (__) -

Insurance Information

Primary Insurance: ______________________ Policy #: ________________ Secondary Insurance: ____________________ Policy #: ________________

Authorization Statement

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

Terms and Conditions

1. I understand that I am financially responsible for all charges whether or not paid by insurance.
2. I authorize the use of my signature on all insurance submissions.
3. I authorize the release of all medical information necessary to process insurance claims.
4. I understand that copayments and deductibles are due at the time of service.
5. I acknowledge that this authorization specifically applies to all vascular surgery procedures, diagnostic testing, and related services.

Medicare/Medicaid Authorization (if applicable)

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

Signature Section

Patient/Guardian Signature: ___________________________ Date: //___

Print Name: ______________________________________

Witness: ________________________________________

Office Use Only

Received by: _____________________________________ Date: //___ Verified by: _____________________________________ Date: //___

This authorization remains in effect until revoked in writing by the patient/guardian.