Assignment Of Benefits Form (Page 2 of 2) in pdf

Assignment Of Benefits Form Page 2

Assignment of Benefits

In order for us to bill Medicaid and/or other insurance for your medical

supply(s), this form must be completed, signed and returned immediately.

• I, the undersigned, hereby authorize assignments of and direct billing to

Medicaid and/or other insurance benefits to [name of company] for

supplies furnished to me.

• I further agree and acknowledge that my signature on this document

authorizes [name of company] to obtain and release any medical and

billing information to Medicaid and/or other insurers necessary to process

my claim(s), including determining eligibility and seeking reimbursement

for supplies provided.

• I request that payment of authorized benefits be made to [name of

company] on my behalf, for supplies furnished to me.

• I will be responsible for my insurance deductible.

• If my insurance company reimburses me directly instead of [name of

company], I will submit payment in the same amount to them.

Print Patient's Name

_______________________________________________________

Patient’s Signature

________________________________________________________

Guardian Signature

_______________________________________________________

Date

______________________

Assignment Of Benefits Form Page 2