Common Contracts
1 similar Assignment of Benefits Agreement contracts
Ins. Company __________________________________________ ID# _____________________________________________________ Name of Policy Holder ________________________________Assignment of Benefits Agreement • June 30th, 2020
In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign at clinic’s request, and convey directly to Apex Health Spine & Sport all medical benefits and/or insurance reimbursement, if any, otherwise payab¬le to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I hereby authorize the doctor to release any and all medical
