ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC. Please review the document Consent to Xxxx and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: Patient Care and Financial Responsibility Agreement, Patient Care and Financial Responsibility Agreement
ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC. Please review the document Consent to Xxxx Bill and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: Patient Care and Financial Responsibility Agreement, Patient Care and Financial Responsibility Agreement
ASSIGNMENT OF INSURANCE BENEFITS. I hereby request and authorize that any and all insurance benefits due and payable for medical and psychiatric services and rendered to me are to be paid directly to Gladstone Psychiatry & Wellness, LLC. Please review the document Consent to Xxxx and Release Medical Information to Insurance Company on page 7 of this document for further details.
Appears in 2 contracts
Samples: Patient Care and Financial Responsibility Agreement, Patient Care and Financial Responsibility Agreement
