Nutrition Services Assignment of Benefits Form

Patient Information

Name: ________________________________ Date of Birth: _________________________ Insurance ID: __________________________

Authorization Statement

I, the undersigned, authorize direct payment of medical benefits to [Practice Name] for nutrition services rendered. I understand that I am financially responsible for any charges not covered by my insurance carrier.

Terms and Conditions

1. Insurance Coverage

   • I certify that the insurance information provided is current and accurate
   • I understand that verification of benefits is not a guarantee of payment

2. Financial Responsibility

   • I agree to pay any deductibles, co-payments, or non-covered services
   • I understand that unpaid balances may be subject to collection procedures

3. Service Authorization

   • I authorize the release of medical information necessary to process claims
   • I permit a copy of this authorization to be used in place of the original

Signatures

Patient Signature: _____________________ Date: ________________________________

If signed by representative: Representative Name: __________________ Relationship to Patient: _______________

Practice Information

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

This authorization remains in effect until revoked in writing by the patient or representative.