Patient Payment Form Page 2
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2Abington - Jefferson Health
Please sign below. This is requred for your benefits to be paid directly to the practice.
REQUEST FOR PAYMENT AND ASSIGNMENT OF BENEFITS
I request payment and authorize any healthcare benefits that are otherwise payable to me by any insurance provider,
benefit plan or other third party payer, under the terms of the insurance policy or benefit plan be paid directly to
Abington Health Physicians (AHP). I understand that:
* I may be responsible for payment in full of any amount due that is not covered or paid for by any insurance policy
or benefit plan.
* If my account is referred to an attorney or agency for collection of any unpaid balances for which I am responsible,
that I will also be responsible for reasonable attorney’s fees and collection expenses.
* My obligation to pay may not be deferred for any reason, including pending legal actions against other parties to
recover medical costs.
RELEASE OF INFORMATION
I authorize AHP and/or their agents:
* To give the insurance provider, benefit plan, or other third party payer, or their agents, any medical or other
information necessary to receive payment or obtain authorization for services, supplies and equipment.
* To request and receive directly, on my behalf, any information related to my insurance policy or benefit plan
(including, but not limited to, proof of my healthcare benefits).
* To file, on behalf of themselves or on my behalf, claims for benefits and/or appeals of any denied claims or
authorization and to take action in my name against any insurance company, benefit plan or other third party
payer, to receive any benefits that may be due or payable under the insurance policy or benefit plan.
* To give medical or other information to any healthcare practitioner providing healthcare services to me or receive
information from them.
STATEMENT OF ASSISTANCE
I agree::
* To assist AHP in collecting benefits that may be due or payable under my insurance policy or benefit plan for the
services, supplies and equipment provided.
* To provide any additional information needed to process the claim for payment.
* That a photocopy or other reproduction of this document shall be considered as valid as the original.
___________________________________________________
______________________
________________
Signature of Patient / Signature of Person Authorized to Consent for Patient
Relationship to Patient
Date
_____________________________________________________________
________________
Signature of Witness
Date
_____________________________________________________________
If the patient is unable to sign upon arrival, state the reason and initial
I certify that the information on this form is correct and current:
Date: ___________________
Signature: ______________________________________
Date: ___________________
Signature: ______________________________________
Date: ___________________
Signature: ______________________________________
For office use only:
Authorization Number_______________________________ Dates ____________________
Review necessary? ____________________________________________________________
Form should be completed at patient’s first visit, whenever changes are indicated or at least annually per policy.
Updated 5/2016
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