Neurology Assignment of Benefits Agreement

[Practice Name] [Address] [City, State ZIP] [Phone]

Patient Information

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

Insurance Information

Primary Insurance: ______________ Policy #: _________________ Secondary Insurance: ____________ Policy #: _________________

Authorization and Agreement

I, the undersigned, hereby authorize [Practice Name] to submit claims on my behalf directly to my insurance carrier(s) for neurological services rendered. I authorize payment of medical benefits directly to [Practice Name] for these services.

Terms and Conditions

1. I understand that I am financially responsible for all charges, whether or not paid by my insurance carrier, including:

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

2. I authorize the release of any medical information necessary to process insurance claims related to my neurological care.

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

4. I acknowledge that:

   • This assignment applies to all current and future neurological treatment
   • I am responsible for updating insurance information promptly
   • Any denied claims due to incorrect insurance information are my responsibility

Signature Section

Patient Signature: _________________ Date: _______________

If signed by representative: Name: ___________________________ Relationship: __________

Witness: _________________________ Date: _______________

This document is valid for one year from the date of signature unless revoked earlier in writing.