Common Contracts
3 similar Insurance Agreement contracts
INSURANCE AGREEMENT DIRECT PAYMENT ASSIGNMENT & INFORMATION RELEASEInsurance Agreement • July 3rd, 2024
I/We hereby name the Doctor(s) and/or Medical Practice given below, hereafter referred to as DOCTOR, as my/our assignee. I/We instruct my/our health care benefits plan provider (i.e., insurance company, HMO, employer, union, or government-run health plan), hereafter referred to as the PLAN, to pay the DOCTOR directly for all professional and medical services provided. Payment should be made by means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed directly to the DOCTOR: Podiatry Associates of IN, P.C. 5471 Georgetown Rd STE C, Indianapolis, IN 46254
INSURANCE AGREEMENT DIRECT PAYMENT ASSIGNMENT & INFORMATION RELEASEInsurance Agreement • September 5th, 2023
I/We hereby name the Doctor(s) and/or Medical Practice given below, hereafter referred to as DOCTOR, as my/our assignee. I/We instruct my/our health care benefits plan provider (i.e., insurance company, HMO, employer, union, or government-run health plan), hereafter referred to as the PLAN, to pay the DOCTOR directly for all professional and medical services provided. Payment should be made by means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed directly to the DOCTOR: Podiatry Associates of IN, P.C. 5471 Georgetown Rd STE C, Indianapolis, IN 46254
INSURANCE AGREEMENT DIRECT PAYMENT ASSIGNMENT & INFORMATION RELEASEInsurance Agreement • September 21st, 2022
I/We hereby name the Doctor(s) and/or Medical Practice given below, hereafter referred to as DOCTOR, as my/our assignee. I/We instruct my/our health care benefits plan provider (i.e., insurance company, HMO, employer, union, or government-run health plan), hereafter referred to as the PLAN, to pay the DOCTOR directly for all professional and medical services provided. Payment should be made by means of electronic funds transfer(s) (EFT) or by check(s) made payable to and mailed directly to the DOCTOR: Podiatry Associates of IN, P.C. 5471 Georgetown Rd STE C, Indianapolis, IN 46254
