Medical Insurance - assignment of benefits/payments
I, the undersigned have medical insurance coverage with Name of Insurance and assign directly to Dr. Aparna Chandrasekaran (Jersey Medical Weight Loss/ Aparna Medical Associates) all medical benefits, if any, otherwise payable to me for services rendered. I authorize release of all the information necessary to secure the payment of benefit. Also, I understand that I am financially responsible for all charges if not paid by the insurance and authorize the use of my signature on all my insurance submission.
By signing below, I certify that all the information I provided is true, correct & complete.