ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • February 12th, 2014
I, (the patient) hereby assign my right to pursue a claim for reimbursement of Personal Injury Protection Benefits rendered by the medical provider who has signed this agreement (or designated an authorized representative to sign on his/her behalf) and his/her employees under the applicable insurance policy against Liberty Mutual Insurance Company. This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I acknowledge that the medical provider’s failure to honor the obligations set forth below render this assignment void. Nothing in this assignment authorizes the medical provider and/or its agents to pursue a claim for bodily injuries on my behalf. Furthermore, I authorize the release of medical records to the insurer and a photocopy of this document shall be considered as effective and valid as the original.
ASSIGNMENT OF BENEFITS, RELEASE OF INFORMATION, AND AGREEMENT FOR PAYMENT OF SERVICES RENDEREDAssignment of Benefits Agreement • September 11th, 2019
Assignment of Benefits AgreementAssignment of Benefits Agreement • October 24th, 2023
This Assignment of Benefits shall be deemed ongoing until my dental insurance company/carrier receives written notice from me that I have revoked this agreement.
ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • January 15th, 2015
I, (the patient) hereby assign my right to pursue a claim for reimbursement of Personal Injury Protection Benefits rendered by the medical provider who has signed this agreement (or designated an authorized representative to sign on his/her behalf) and his/her employees under the applicable insurance policy against Liberty Mutual Insurance Company. This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I acknowledge that the medical provider’s failure to honor the obligations set forth below render this assignment void. Nothing in this assignment authorizes the medical provider and/or its agents to pursue a claim for bodily injuries on my behalf. Furthermore, I authorize the release of medical records to the insurer and a photocopy of this document shall be considered as effective and valid as the original.
Assignment Of Benefits AgreementAssignment of Benefits Agreement • October 18th, 2018
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • April 14th, 2006
Our office will accept an assignment of benefits from your insurance company with the provisions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
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
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • January 31st, 2022
The University of New England Oral Health Center is pleased to accept your insurance assignment if you are in active status with Maine Care and or are in a participating Delta Dental plan at the date of service. We will bill your dental carrier for the services performed as a courtesy, we will collect all co-pays and deductibles prior to treatment commencing. We will not be responsible for inaccurate estimates of co-pays or benefits, as payment by your dental carrier is not guaranteed. Ultimately any services denied or not paid by your insurance become patient responsibility. Dental insurance payments are generally received within 30 days from time of billing. If we have not received insurance payment at the end of 60 days, we reserve the right to bill the patient for the remaining balance and the patient may seek direct reimbursement from the insurance company. If you should have questions or concerns as to your dental coverage for a particular procedure, we recommend you either conta
ASSIGNMENT OF BENEFITS AGREEMENT FOR COSSICH FAMILY DENTISTRYAssignment of Benefits Agreement • October 16th, 2017
Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • May 13th, 2021
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your medical/vision benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENT FOR MG DENTISTRYAssignment of Benefits Agreement • June 26th, 2014
Although we will complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to save you time and to facilitate payment to our practice from your insurance company. By having our practice process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • February 2nd, 2021
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your medical benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • March 2nd, 2018
Our practice will accept an assignment from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
THE FOLLOWING TERMS ON BOTH SIDES ARE AGREED TO BY THE CUSTOMER & SFR SERVICES LLC (CGC#1528824 & CCC#1332477) MUST BE SIGNED BY ALL POLICYHOLDERSAssignment of Benefits Agreement • March 25th, 2020
I, the owner of the above property, authorize SFR Services, to enter my property and provide all services and furnish all materials neces- sary to preserve and protect my property from further damage. Additionally, in consideration for these repairs and SFR Services’ promise to provide all work approved or paid for by my insurance company, I agree to assign my insurance benefits to SFR Services, subject to the terms and conditions in this contract. This Assignment of Benefits is effective on the date last signed (“Effective Date”), between the undersigned customer(s) (“Customer”) and SFR Services, LLC ("Company") (collectively, “Parties”), subject to the terms and conditions herein:
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • May 24th, 2010
Assignment of Benefits AgreementAssignment of Benefits Agreement • June 11th, 2021
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
Assignment of Benefits AgreementAssignment of Benefits Agreement • May 4th, 2023
Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • November 26th, 2008
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • May 8th, 2017
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENT & DISCLOSURE REQUIREMENTSAssignment of Benefits Agreement • May 28th, 2014
I, (the patient) hereby assign my right to pursue a claim for reimbursement of Personal Injury Protection Benefits rendered by the medical provider who has signed this agreement (or designated an authorized representative to sign on his/her behalf) and his/her employees under the applicable insurance policy against Mercer Insurance Company (members of United Fire Group). This assignment is expressly contingent upon the medical provider agreeing to the terms set forth in the Medical Provider Agreement below and I
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • June 23rd, 2010
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have to our practice is to pay for your treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • March 8th, 2010
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • May 24th, 2013
Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • April 10th, 2020
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand however, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • July 22nd, 2020
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand the contract regarding your dental benefits is between you, your employer, and/or your insurance company. The patient has the responsibility to pay our practice for treatment, regardless of the amount we may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • March 5th, 2018
Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • March 20th, 2013
As a special help to our patients, LITTLE FISH DENTAL will be pleased to accept an assignment of benefits from you insurance company with the provisions listed and agreed to below.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • August 1st, 2017
Our practice will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • December 18th, 2020
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your mental health benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • November 6th, 2015
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • September 27th, 2021
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your mental health benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • April 27th, 2008
Our practice will accept an assignment of benefits from your insurance company with the conditions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice to pay for all treatment and services we provide to you, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • April 30th, 2017
Our office will accept an assignment of benefits from your insurance company with the provisions listed below. It is important to understand, though, that the agreement regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • August 13th, 2016
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
ASSIGNMENT OF BENEFITS AGREEMENTAssignment of Benefits Agreement • September 28th, 2021
Our office will accept an assignment of benefits from your insurance company with the following provisions. The following provisions identify our policies governing insurance claims.
