Physical Therapy Assignment of Benefits Agreement

I, _______________________ ("Patient"), hereby authorize and assign my insurance benefits to _______________________ ("Physical Therapy Practice") for services rendered.

Insurance Authorization

• I authorize the release of any medical information necessary to process insurance claims
• I authorize direct payment of medical benefits to the Physical Therapy Practice
• I understand that verification of benefits is not a guarantee of payment

Financial Responsibility

1. I acknowledge responsibility for:

   • All co-payments, deductibles, and co-insurance amounts
   • Services denied by insurance as non-covered or not medically necessary
   • Services not covered by my insurance plan

2. I agree to pay all amounts due at the time of service unless other arrangements have been made

Authorization for Treatment

I authorize treatment and agree to pay all charges for physical therapy care and treatment.

Medicare Patients (if applicable)

• I request payment of authorized Medicare benefits to be made on my behalf
• I authorize release of medical information needed to determine benefits

Acknowledgment

I have read and understand this assignment of benefits agreement.

Patient Signature: _______________________ Date: _______________________

Witness Signature: _______________________ Date: _______________________

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