Benefit Assignment Form printable pdf download

Benefit Assignment Form

Instructions: This form must be filled out when claim payment is assigned to the Provider. Please retain

this form in the patient’s file for verification purposes for two years following closure of the patient file.

Provider: ______________________________________

Address: _______________________________________

City/Province: ___________________________________

Postal Code: ____________________________________

Phone Number: __________________________________

Patient: ________________________________________

Address: ________________________________________

City/Province: ____________________________________

Postal Code: _____________________________________

Phone Number: ___________________________________

Plan Number: ____________________________________

Certificate / Plan member Number: ___________________

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my

claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue

payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I

understand that I remain responsible for payment to the Provider for any services rendered and/ or

supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this

Assignment, that any benefit payment made in accordance with this Assignment will discharge the

insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the

benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with

respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider

and that I may revoke it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an

assignment of benefit payments to the Provider.

________________________

___________________________

Date:

Signature

Print Name:

Benefit Assignment Form