Common Contracts
1 similar Assignment and Release contracts
ASSIGNMENT AND RELEASEAssignment and Release • October 30th, 2022
I, the undersigned, have insurance with and assign directly to Dr. Ronnie L. Hold, Jr. all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
