ASSIGNMENT AND RLEASE
I, the undersigned certify that I (or my dependent) have insurance coverage
and assign directly to
all insurance 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 insurance submissions.
Best time to reach you
IN CASE OF EMERGENCY, CONTACT
(Specify someone who does not live in your household.)
Check “Yes” or “No” where indicated for all
Place a mark on “Yes” or “No” to indicate if you have had any of the following:
( To be filled in at future appointments)