Assignment Of Benefits, Direction To Pay And Release Of Information Form

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ASSIGNMENT OF BENEFITS, DIRECTION TO PAY, & RELEASE OF
INFORMATION:
ASSIGNMENT OF BENEFITS: The undersigned patient assigns the benefits of insurance and
any overdue interest payments under the No-fault Policy of Automobile Insurance, also known
as Personal Injury Protection (P.I.P.), or Medicare Payments Policy of Insurance with my
insurance carrier or the responsible insurer to SOUTHWEST ORTHOPEDIC GROUP,
L.L.P./STEPHEN ESSES, M.D. for services rendered. The medical provider agrees to accept
the irrevocable assignment of benefits rendered to the patient. This assignment applies to both
past and future medical expenses. A photocopy of this assignment is to be considered as valid
and original. The undersigned patient agrees to pay any applicable deductible, co-payments, or
any and all other services not covered by the insurance policy. DIRECTION TO PAY: The
undersigned patient further directs the insurer to pay SOUTHWEST ORTHOPEDIC GROUP,
L.L.P./STEPHEN ESSES, M.D. directly for the services rendered.
RELEASE OF
INFORMATION:
I
hereby
authorize
SOUTHWEST
ORTHOPEDIC
GROUP,
L.L.P./STEPHEN ESSES, M.D. to furnish my insurance company or companies, or their
representatives with any and all information that may be contained in their medical records.
X______________________________________________ Date: __________________
(Patient’s signature or parent’s signature if patient is a minor)
LIFETIME MEDICARE PART B SIGNATURE AUTHORIZATION: I authorize my
holder of medical or other information about me to release to the Social Security Administration,
its intermediaries, carriers, or the billing agent of SOUTHWEST ORTHOPEDIC GROUP,
L.L.P./STEPHEN ESSES, M.D. any information needed for this or a related Medicare claim. I
permit a copy of this authorization to be used in place of the original, and request payment of
medical insurance benefits be made to the holder of this assignment on my behalf. I understand
that I am responsible for any health deductibles and insurance.
X__________________________Date:_____________Medicare#:__________________
(Medicare signature only)
IF PATIENT IS UNDER 18:
I hereby give my permission for _________________________________to be treated by
Dr. _____________________________________.
X______________________________________________Date:____________________
Patient unable to sign due to _______________________________________________.
Witness X_______________________________________Date:____________________

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