Chiropractic Assignment of Benefits Agreement

Patient Information

Name: ________________________________
Date of Birth: __________________________
Address: _______________________________
Phone: ________________________________

Insurance Information

Primary Insurance: ______________________
Policy Number: _________________________
Group Number: __________________________

Assignment of Benefits

I, the undersigned, hereby authorize and direct my insurance carrier(s) to pay directly to:

Chiropractor/Practice Name: _____________________________________________
Address: ___________________________________________________________

any and all chiropractic benefits due to me under my insurance policy for services rendered by this office.

Authorization Statements

1. I understand that I am financially responsible for all charges not covered by my insurance.

2. I authorize the release of any medical information necessary to process insurance claims.

3. I permit a copy of this authorization to be used in place of the original.

4. This assignment will remain in effect until revoked by me in writing.

5. I understand that this assignment does not relieve me of my obligation to pay such bills if not paid by my insurance company for any reason.

Acknowledgment

Patient Signature: _________________________
Date: ___________________________________

Witness: _________________________________
Date: ___________________________________

This document constitutes a legal agreement between the patient and the practice regarding the assignment of insurance benefits.