Urgent Care Assignment of Benefits Form

I, _________________________________ (print patient name), hereby authorize [URGENT CARE NAME] to apply for benefits on my behalf for services rendered.

Insurance Authorization

I certify that the insurance information I have provided is correct. I authorize the release of any medical information necessary to process insurance claims. I understand that I am financially responsible for all charges whether paid by insurance or not.

Payment Authorization

• I authorize payment of medical benefits directly to [URGENT CARE NAME]
• I understand that I am responsible for any amount not covered by my insurance
• I agree to pay all copayments, coinsurance, and deductibles at the time of service

Medical Information Release

I authorize the release of any medical information necessary to:

1. Process this claim
2. Facilitate treatment
3. Coordinate care with other healthcare providers

Financial Agreement

I understand and agree that:

• Payment is due at the time of service
• There will be a fee for returned checks
• Unpaid balances may be referred to collections
• I am responsible for any collection costs incurred

Signatures

Patient/Guardian Signature: _______________________________

Date: _______________

Witness Signature: _______________________________________

Date: _______________

This authorization remains in effect until revoked in writing.