Pediatric Assignment of Benefits Agreement

Patient Information

Patient Name: _________________________ Date of Birth: _____________ Parent/Legal Guardian Name: ______________________________________

Agreement Terms

I, the undersigned parent/legal guardian of the above-named minor patient, hereby authorize and direct my insurance carrier(s) to pay directly to:

Insurance Benefits Assignment

I hereby assign all medical and/or surgical benefits to which I am entitled, including:

• Private health insurance
• Medicare/Medicaid
• Other health plans

Financial Responsibility

I understand that:

1. I am financially responsible for all charges whether paid by insurance or not
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

Authorization for Treatment

I authorize treatment of the minor patient named above and agree to pay all fees and charges for such treatment. I understand that:

• Health insurance policies are an arrangement between my insurance carrier and me
• This medical practice will help prepare and submit insurance claims
• Not all services are covered benefits under all contracts

Signatures

Parent/Guardian Signature: ______________________ Date: ____________

Witness: _____________________________________ Date: ____________

Practice Authorization

Practice Representative: ________________________ Date: ____________