Dermatology Assignment of Benefits Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Insurance Information

Primary Insurance: ______________ Policy #: _________________ Subscriber Name: _______________ Group #: _________________

Authorization Statement

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above-named insurance company 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 information necessary to secure payment of benefits.
4. I authorize [PRACTICE NAME] to release any medical information required to process my claims.

Specific Authorizations

• I authorize the release of any medical information necessary to process insurance claims
• I authorize payment of medical benefits to [PRACTICE NAME] for dermatology services provided
• I understand that this authorization remains valid until revoked by me in writing

Financial Agreement

I agree to pay for all services rendered, including:

• Deductibles
• Co-payments
• Co-insurance amounts
• Non-covered services

Signature: ______________________ Date: ___________________

Print Name: _____________________

Office Use Only

Received by: ____________________ Date: ___________________