Cardiology Assignment of Benefits Agreement

Patient Information

Name: ________________________________ Date of Birth: _________________________ Account Number: _______________________

Authorization

I, the undersigned, authorize direct payment to [CARDIOLOGY PRACTICE NAME] of any medical benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by my insurance carrier.

Insurance Benefits Assignment

I hereby assign all medical and/or surgical benefits, including major medical benefits to which I am entitled, private insurance, and any other health plan to [CARDIOLOGY PRACTICE NAME]. This assignment will remain in effect until revoked by me in writing.

Financial Responsibility Agreement

• I understand that I am responsible for all copayments, deductibles, and coinsurance amounts
• I acknowledge that some services may not be covered by my insurance plan
• I agree to pay for services that are not covered by my insurance
• I understand that payment is due at the time of service unless other arrangements have been made

Medical Information Release

I authorize the release of any medical information necessary to:

1. Process insurance claims
2. Ensure payment for services rendered
3. Comply with regulatory requirements

Acknowledgment

Patient Signature: ____________________ Date: _______________________________

Witness: ____________________________ Date: _______________________________

OFFICE USE ONLY Processed by: ________________________ Date: _______________________________