By signing this form, you (the patient or the patient’s legal guardian) are assigning payment of your health insurance benefits directly to Modern Medical Group for medical services provided. This allows Modern Medical Group to bill your insurance company and receive payment on your behalf.
I hereby authorize payment of medical benefits, including but not limited to medical, surgical, diagnostic, and therapeutic services, directly to Modern Medical Group Inc dba Motion Foot and Ankle for services rendered. I understand that this authorization applies to all insurance companies or third-party payers from which I may be entitled to receive benefits, including Medicare and Medicaid if applicable.I also understand and agree that:Insurance Coverage: This assignment of benefits does not absolve me of financial responsibility for any charges not covered by my insurance. I am responsible for paying any deductibles, co-payments, co-insurance, or any other fees that my insurance plan does not cover, as well as any charges for services that are not deemed medically necessary or are otherwise not reimbursed by my insurer.Right to Appeal: I authorize Modern Medical Group Inc dba Motion Foot and Ankle to appeal claims on my behalf and provide any necessary information to process my insurance claims.Release of Information: I authorize Modern Medical Group Inc dba Motion Foot and Ankle to release any medical information required by my insurance company, third-party payer, or their agents to determine the benefits payable for the services provided.Insurance Denial: If my insurance company denies payment for any reason, I understand that I am financially responsible for the total amount of services provided. I agree to remit payment for any outstanding balances promptly.Revocation of Authorization: This assignment will remain in effect until revoked by me in writing. However, I understand that my revocation will not affect any actions taken by Modern Medical Group Inc dba Motion Foot and Ankle prior to receiving my written revocation.
I have read and fully understand this Assignment of Benefits and the terms outlined above. I hereby authorize my insurance company to make payment directly to Modern Medical Group Inc dba Motion Foot and Ankle for services rendered.blanksblank
Staff Member Name: _______________________________________Date: _________________________________________________Effective Date: 06/01/2024This form must be retained in the patient's medical record for legal and insurance purposes.This document ensures that the healthcare provider receives payments directly from the insurance carrier and clarifies the patient’s financial responsibility for any uncovered charges.