Assignment Of Benefits - Texas Family Eyecare
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1ASSIGNMENT OF BENEFITS
Financial Responsibility
I understand that insurance billing is a service provided as a courtesy and that I am at all times
financially responsible to Texas Family Eyecare and/or its affiliated entities for any charges not
covered by health care benefits. It is my responsibility to notify Texas Family Eyecare of any changes
in my health care coverage. In some cases exact insurance benefits can not be determined until the
insurance company receives the claim. I am responsible for the entire bill or balance of the bill as
determined by Texas Family Eyecare and/or my health care insurer if the submitted claims or any
part of them are denied for payment. I understand that by signing this form that I am accepting
financial responsibility as explained above for all payment for medical services and/or supplies
received.
Assignment of Benefits
I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a
Medicare beneficiary, to Texas Family Eyecare for all covered medical services and supplies
provided to me during all courses of treatment and care provided by Texas Family Eyecare and/or its
affiliated entities or otherwise at its direction. I understand and agree this Assignment of Benefits will
have continuing effect for so long as I am being treated or cared for by Texas Family Eyecare and will
constitute a continuing authorization, maintained on file with Texas Family Eyecare, which will
authorize and allow for direct payment to Texas Family Eyecare of all applicable and eligible
insurance benefits for all subsequent and continuing treatment, services, supplies and/or care
provided to me by Texas Family Eyecare.
Authorization to Release Information
I authorize the release of any medical or any other information to the Health Care Financing
Administration, my insurance carrier(s), or other entity necessary to determine insurance benefits or
the benefits payable for related medical services and/or supplies provided to me by Texas Family
Eyecare. A copy of this authorization will be sent to the Health Care Financing Administration, my
insurance carrier(s), or other medical entity, if requested. The original authorization will be kept on file
by Texas Family Eyecare.
___________________________
__________________
_____________________
Patient/Insured (Printed Name)
Date of Birth
Social Security Number
___________________________
__________________
Patient/Insured (Signature)
Date of Signature
___________________________
__________________
Witness (Signature)
Date of Signature
HIPAA Notification
I, _________________________, have been presented with the Notice of Privacy Policy of Texas
Family Eyecare and have been offered a copy of such policy.
_____________________________
____________________
Patient/Guardian Signature
Date of Signature
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