Assignment Of Benefits Form - Highland Clinic printable pdf download

HIGHLAND CLINIC

A Professional Medical Corporation

_________________________________________

Patient Name

(Please Print)

(Receptionist Only)

_________________________________________

Med. Rec. # __________________

Responsible Party

(Please Print)

(Receptionist Only)

Assignment of Benefits

I authorize payment of medical benefits under any insurance policy(ies) or other settlement, if any, to Highland Clinic,

A.P.M.C., for any medical services.

INDEMNITY INSURANCE ASSIGNMENT OF BENEFITS:

I agree to pay Highland Clinic, A.P.M.C., for all charges in excess of the amounts paid by my insurance policy(ies).

I understand it is my responsibility to determine whether your services are covered by my insurance policy(ies). A

photostatic copy of this authorization shall be considered as valid as the original.

MANAGED CARE ASSIGNMENT OF BENEFITS (HMO/PPO):

I agree to pay Highland Clinic, A.P.M.C., for copayments, deductibles or charges for services which are not covered under

my Member’s Benefits contract.

Authority to Release Information

Highland Clinic, A.P.M.C., is authorized to release information or facts, including substance abuse or mental diagnosis to

my insurance carrier or their representative for their use in determining a claim for payment on my behalf or for use in any

audit of the records of Highland Clinic, A.P.M.C. by any insurance carrier, HMO or third party payor. A photostatic copy

of this authorization shall be considered as valid as the original.

Disclosure Statement and Billing Information

I hereby acknowledge that I have read the Authority to Release Information and Billing Rights (on the reverse) and agree

to all terms herein and further acknowledge receipt of copy of disclosure statement.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of

information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this consent, and

The right to request restrictions as to how my health information may be used or disclosed to carry out

treatment, payment or health care operations

I wish to have the following restrictions and/or authorizations to the use or disclosure of my health information:

_________________________________________________________________________________________

____________________________________________

__________________________________________

Date

Signature of Patient

____________________________________________

__________________________________________

Date

Signature of Responsible Party

(if patient is a minor)

HC 0121AF

Assignment Of Benefits Form - Highland Clinic

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