Gastroenterology Assignment of Benefits Form

Patient Information

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

Authorization Statement

I, the undersigned, authorize direct payment to [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.

Agreement Terms

1. 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
   • This authorization remains valid until revoked by me in writing

2. Financial Responsibility

   • I agree to pay any deductible, co-insurance, or co-payment at the time of service
   • I understand that I am responsible for any amount not covered by my insurance
   • I agree to pay all reasonable costs of collection, including attorney fees

3. Specific Procedures

   • This includes but is not limited to:
     • Endoscopic procedures
     • Colonoscopy
     • Liver biopsy
     • Other diagnostic procedures

Signature

Patient/Guardian Signature: _________________ Date: __________

Print Name: ____________________________

Practice Information

[Practice Name] [Address] [Phone] [License/Certification Numbers]