Assignment Of Medicare Benefits - Columbus Eye Associates

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ASSIGNMENT OF MEDICARE BENEFITS
PATIENT NAME:__________________
MEDICARE NUMBER : ____________________________
I request that payment of authorized Medicare benefits be made on my behalf to
COLUMBUS EYE ASSOCIATES
For any service furnished to me by a physician of the group. I authorize any holder of
medical information about me to release to the Health Care Financing Administration and
its agents any information needed to determine these benefits payable for related services.
In Medicare assigned cases, the provider agrees to accept the charge determination of the
Medicare carrier and I am responsible for the Medicare deductible, co-insurance or the
20% Medicare does not pay, and for any non-covered services.
My signature below further verifies that I have not joined an HMO or other entity in
which my Medicare benefits have been relinquished.
SIGNATURE: ________________________________________________
DATE: ___________________________
MEDIGAP OR OTHER SECONDARY INSURANCE
I request that the payment of authorized Medigap benefits be made either by me or on my
behalf to COLUMBUS EYE ASSOCIATES, or any physician of that group, for
services provided to me by a physician of the group. I authorize any holder of medical
information about me to release it to my Medigap insurer, ____________, or any
information needed to determine these benefits for related services.
The assignment shall remain in effect until revoked by me in writing. A photocopy of this
assignment is considered as valid as the original.
SIGNATURE: ________________________________________________
DATE:______________________________

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