Orthopedic Practice Assignment of Benefits Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ SSN: __________________________ Account #: ____________________

Agreement Terms

I, the undersigned, certify that I (or my dependent) have insurance coverage with _______________________ and assign directly to [PRACTICE NAME] all insurance benefits, if any, otherwise payable to me for services rendered.

Authorization

I hereby authorize:

1. The release of any medical information necessary to process insurance claims
2. Direct payment of all medical/surgical benefits to [PRACTICE NAME]
3. The use of this signature on all insurance submissions
4. My healthcare provider to act as my agent in helping obtain payment from my insurance companies

Financial Responsibility

I understand that:

• I am financially responsible for all charges whether paid by insurance or not
• Copayments and deductibles are due at the time of service
• If my insurance company denies payment, I agree to be personally and fully responsible for payment
• All account balances over 90 days may be subject to collection proceedings

Signatures

Patient/Guardian Signature: _________________ Date: ____________

Print Name: ______________________________ Relationship: _______

Practice Information

[PRACTICE NAME] Address: _______________________________ Phone: ________________________________ NPI: __________________________________

This authorization remains in effect until revoked in writing.