FORM4: Insurance Benefit Assignment Form

EYETELLIGENCE

FORM4: INSURANCE BENEFIT ASSIGNMENT FORM
Welcome to our clinic. We are pleased to offer this online form to our patients in order to reduce the waiting times and the exposure in a public setting.

The Insurance Benefit Assignment Form needs to be filled ONLY when the claim payment is assigned to the healthcare provider.

Please check with your insurance provider to ensure your plan permits the payment to be assigned to the healthcare provider. Your healthcare provider may be able to file the electronic claim on behalf of you, but the insurance provider may only pay the plan member.

Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

The information provided is strictly confidential.

Please fill out this application completely to the best of your ability.

A copy will be sent to your email address given in this form.

Thank you
EYETELLIGENCE Team

Today's Date

MonthDayYear
PROVIDER PROFILE
Provider*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Email
example@example.com
PATIENT PROFILE
Title*
Name (As shown in your insurance card)*

First NameLast Name
Date of Birth*

MonthDayYear
MaleFemale
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
Insurance Provider*
Employer*
Plan Number*
Certificate / Plan Member Number*

ACKNOWLEDGEMENT
I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for any payment to the Provider for any services rendered and/ or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.
Name*
Patient or Substitute Decision Maker
Signature Date*

MonthDayYear
Signature*

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