Consent To File Insurance/assignment Of Benefits Form printable pdf download

CONSENT TO FILE INSURANCE/ASSIGNMENT OF BENEFITS

PATIENT NAME: ____________________________________________________________________

CALL NUMBER :__________________________________ DATE OF CALL: __________________

SOCIAL SECURITY #______________________________ DATE OF BIRTH___________________

PLEASE COMPLETE THIS FORM AND RETURN IT TO OUR OFFICE AS SOON AS POSSIBLE.

ALL

INFORMATION IS NEEDED TO FILE CLAIMS WITH YOUR INSURANCE CARRIER. PLEASE BE SURE TO

SIGN THIS FORM INDICATING YOUR CONSENT TO PAY US DIRECTLY. NAMES SHOULD BE EXACTLY AS

THEY APPEAR ON YOUR INSURANCE CARD.

MEDICARE NUMBER: ________________________________________________________________

PRIMARY

SECONDARY

MEDICAID NUMBER: ________________________________________________________________

PRIMARY

SECONDARY

IF AUTO ACCIDENT GIVE AUTO CARRIER, POLICY NUMBER AND CLAIM NUMBER. USE HEALTH

INSURANCE CARRIER AS SECONDARY

PRIMARY INSURANCE:

INSURANCE COMPANY NAME: _______________________________________________________

ADDRESS: __________________________________________________________________________

CITY/STATE/ZIP: ____________________________________________________________________

INSURANCE COMPANY TELEPHONE NUMBER:_________________________________________

POLICY HOLDER (IF OTHER THAN PATIENT):___________________________________________

DATE OF BIRTH: ___________________ SOCIAL SECURITY # _____________________________

GROUP NUMBER: __________________________POLICY # ________________________________

SECONDARY INSURANCE:

INSURANCE COMPANY NAME: _______________________________________________________

ADDRESS: __________________________________________________________________________

CITY/STATE/ ZIP:_____________________________________________________________________

INSURANCE COMPANY TELEPHONE NUMBER: ________________________________________

POLICY HOLDER (IF OTHER THAN PATIENT): __________________________________________

GROUP NUMBER: _________________________ POLICY # ________________________________

DATE OF BIRTH: __________________________SOCIAL SECURITY#:_______________________

I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE/MEDICAID/INSURANCE BENEFITS BE MADE

EITHER TO ME OR ON MY BEHALF TO NASSAU COUNTY BOARD OF COUNTY COMMISSIONERS FOR

RESCUE SERVICES FURNISHED TO ME BY THAT SUPPLIER. I AUTHORIZE ANY HOLDER OF HOSPITAL

OR MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING

ADMINISTRATION AND ITS AGENTS AND CARRIERS AS WELL AS TO NASSAU COUNTY BOARD OF

COUNTY COMMISSIONERS ANY INFORMATION OR DOCUMENTATION NEEDED TO DETERMINE THESE

BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

I PERMIT A COPY OF THIS

AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.

I UNDERSTAND THAT THIS

AUTHORIZATION MAY BE USED BY THE SUPPLIER FOR ALL SERVICES IN THE FUTURE UNTIL SUCH

TIME AS I REVOKE THIS AUTHORIZATION IN WRITING.

_________________________________________________

___________________

SIGNATURE AND CONSENT TO PAY DIRECTLY

DATE

Consent To File Insurance/assignment Of Benefits Form

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