Occupational Therapy Assignment of Benefits Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________ Insurance ID: ___________________ Group #: __________________

Authorization Statement

I, the undersigned, hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment directly to:

[Practice Name]
[Address]
[City, State, ZIP]
Tax ID: _________________

Scope of Authorization

This authorization applies to all medical services provided by the above-named occupational therapy practice, including:

• Evaluation and assessment services
• Treatment procedures and interventions
• Equipment and supplies
• Home exercise programs and documentation
• Progress reports and documentation

Terms and Conditions

1. I understand that I am financially responsible for any charges not covered by my insurance carrier(s)
2. This assignment will remain in effect until revoked by me in writing
3. A photocopy of this assignment is considered as valid as the original
4. I authorize the release of any medical information necessary to process claims

Signatures

Patient Signature: _________________ Date: ______________

If signed by representative: Name: __________________________ Relationship: ________

Witness: ________________________ Date: ______________

This form complies with state and federal regulations regarding assignment of benefits