Speech Therapy Assignment of Benefits Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Insurance Information

Primary Insurance: ______________ Policy #: _________________ Secondary Insurance: ____________ Policy #: _________________

Authorization and Agreement

I, _________________________, hereby authorize and direct my insurance carrier(s) to pay directly to:

[Practice Name] [Address] [Phone Number] [NPI Number]

any and all speech therapy benefits due to me under my insurance policy for services rendered by the speech-language pathologist.

Terms and Conditions

1. I understand that I am financially responsible for all charges not covered by my insurance.
2. I authorize the release of any medical information necessary to process insurance claims.
3. I understand that this authorization will remain in effect until revoked by me in writing.
4. I acknowledge that copays are due at the time of service.
5. I agree to notify the practice of any changes in my insurance coverage.

Missed Appointment Policy

I understand that I may be charged for appointments cancelled with less than 24 hours notice.

Signatures

Patient/Guardian Signature: _________________ Date: __________

Witness Signature: _________________________ Date: __________

Office Use Only

Received by: ______________________________ Date: __________