Limited Power Of Attorney/payment Agreement printable pdf download

ASSIGNMENT OF BENEFITS/RELEASE OF RECORDS/

LIMITED POWER OF ATTORNEY/PAYMENT AGREEMENT

ASSIGNMENT OF BENEFITS:

Patient Initial Here:______________

To Insurance Company: _____________________________________________ I hereby direct and instruct you to

make payment directly to the undersigned provider(s) for medical claims submitted by them on my behalf for

medically necessary treatment. This shall also serve as a “Limited Power of Attorney”. Please provide them

with any and all information regarding my policy benefits and coverage. Your denial or delay to do so in a

timely manner will be considered just cause for myself, or provider to file a complaint with the Insurance

Commissioner. I hereby give my permission to the undersigned provider to file this complaint on my behalf if

deemed necessary.

RELEASE OF RECORDS:

Patient Initial Here______________

To Provider of Services: _________________________________________ at IT&B. I hereby authorize you to release

to any attorney, physician or insurance company involved in my case, any medical or other records or

information necessary to process my claim. These records are to be utilized for the ultimate recovery of

benefits in my case for the injury/illness sustained on date ____/____/____.

PAYMENT AGREEMENT:

Patient Initial Here______________

I understand that my insurance contract is an agreement between the insurance company and myself. I

acknowledge that your office is willing to prepare the necessary reports and assist me in collecting from the

insurance company that which is due to you for my medically necessary care and treatment.

I agree and acknowledge that I am ultimately responsible to you for payment of any balance due, including

unpaid deductible and/or unpaid percentage amounts due to you according to my policy coverage, in the

event you are unable to collect from my insurance carrier or attorney in the case where you are holding an

attorney lien on my behalf.

I understand that 6 hours notice is required for cancellation of appointments, and I will be charged for

missed appointments without proper notice at 50% of the normal rate.

I understand I may elect to be billed monthly or at the time of each visit for the balances due to you from each

visit. I elect to pay by Check____

Cash____

Credit Card____

SELECT ONE

1. I elect to pay the unpaid balances at the time of each visit____

2. I elect to be billed for the balance at the end of each month____

3. I elect to have outstanding bills sent to my attorney to be paid at the time of settlement if there is a

settlement; if either no settlement or payment occurs, then I understand and agree that I will be

responsible for payment to you for payment to you for services provided by your facility____

PATIENT’S NAME:________________________________________________________________________________________

ADDRESS: _______________________________________________________________________________________________

PATIENT’S SIGNATURE:___________________________________________________________ DATE:____/____/____

PROVIDER’S SIGNATURE:__________________________________________________________ DATE:____/____/____

/ 5030 S Hwy 17-92 / Suite B / Casselberry, FL 32707 / 407.332.6842

Limited Power Of Attorney/payment Agreement