Patient Registration and Assignment of Benefits Sample Contracts

REGISTRATION

Patient Registration and Assignment of Benefits • October 27th, 2021

• Contract Type
  Patient Registration and Assignment of Benefits
• Filed
  October 27th, 2021

and assign directly to John Carlucci, D.C. all medical 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.

REGISTRATION

Patient Registration and Assignment of Benefits • October 2nd, 2017

• Contract Type
  Patient Registration and Assignment of Benefits
• Filed
  October 2nd, 2017

and assign directly to Dr. all medical 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.