PATIENT NAME:___________________________

DATE OF BIRTH:___________________________

AUTHORIZATON FOR ASSIGNMENT OF BENEFITS

I authorize this practice to apply for benefits from _________________________(insurance carrier) and further authorize payment directly to ____________________.(or in the case of Medicare Part B benefits, to me or to the party who accepts assignment) of the surgical and/or medical benefits, if any, otherwise payable to me for services rendered by the physician in this practice. Medicare Only: I request that payment of authorized Medigap benefits be made either to me or on my behalf to ____________________.for any services furnished to me by physicians. In this practice I authorize any holder of medical information about me to release to__________________________(Medigap insurer) any information needed to determine those benefits or benefits payable for related services.

AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the release of medical information required by my insurance carrier (or, in the case of Medicare Part B benefits, to the Social Security Administration and the Health Care Financing Administration) or its designated review agent, or (if applicable) my employer’s worker’s compensation insurance carrier in order to determine benefits to which I may be entitled, or to designated agents of this practice. This authorization may be revoked either by me or by the above carrier at any time in writing.

FINANCIAL AGREEMENT

I hereby assume financial responsibility for and agree to make payment in full to this practice for any and all charges for services or medical supplies received by me and/or any dependents not otherwise authorized or paid by my insurance carrier. Payment is to be made within 30 days as statements are presented with settlement in full, or payment arrangements to be made with the Billing Office. I certify that the financial information given is true, accurate, and complete to the best of my knowledge, and further authorize, ____________________.to investigate any and all financial information given concerning this or related claims. I further understand that this practice reserves the right to charge interest and/or pursue delinquent accounts via third party collection agencies or attorneys and that I am responsible for any fees and/or court costs incurred by this practice during the collections process.

I also agree to notify the practice of any changes in my billing address or telephone and/or my health insurance carrier information as they occur. This entire authorization is valid for all episodes of care rendered by all and any providers associated with the practice. I permit a copy of this authorization and agreement to be used in place of the original.

YEAR	SIGNATURE OF PATIENT	DATE OF SIGNATURE
2004
2005
2006
2007
2008

Financial Agreement/Authorization for Assignment of Benefits/Release of Information (FRDK 005.B)