Medical Insurance Verification Form

Assignment and Instruction for Direct Payment to Doctor
(Private, Group Accident, and Health Insurance)

Patient*

Employer*

Claim/Group #*

ID #*

I hereby instruct and direct the insurance company, to pay by check made out and mailed directly to:

Anna Marie O’Looney LLC
54 S. Liberty Dr.
Stony Point, NY 10980

If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check out to me and mail it to the address above.

The professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay in a current manner any balance of said professional service charges over and above this insurance payment.

A photocopy of this Assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

Signature of Policy Holder *

Date

Signature of Claimant, if other than policy holder