Endocrinology Assignment of Benefits Form

Patient Information

Name: _______________________________ Date of Birth: _______________ Address: _____________________________ Phone: ____________________ Insurance ID: _________________________ SSN: _____________________

Authorization and Agreement

I, the undersigned, authorize payment of medical benefits to [PRACTICE NAME] for any services furnished to me by the endocrinologist and/or other healthcare providers within the practice. I understand that I am financially responsible for any amount not covered by my insurance contract.

Insurance Authorization

• 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 request that payment of authorized benefits be made on my behalf

Financial Responsibility

1. I understand that I am responsible for all co-payments, deductibles, and non-covered services
2. I acknowledge that I am responsible for updating my insurance information
3. I agree to pay any balance remaining after insurance processing within 30 days

Specific Authorizations

• Laboratory and diagnostic testing related to endocrine disorders
• Hormone replacement therapy and related treatments
• Diabetes management services and supplies
• Thyroid disorder treatments and procedures

Signature

Patient/Guardian Signature: __________________ Date: _______________

Print Name: _______________________________ Relationship: __________

Practice Information

[PRACTICE NAME] [ADDRESS] [PHONE] [FAX] [EMAIL]