Assignment of Benefits (AOB)

The Sensational Child Inc

650 Ten Rod Road North Kingstown, RI 02852

Phone: 401-667-2797, Fax: 401-600-0101

sensationalchildinc@gmail.com
Assignment of Benefits (AOB)

This form is required to bill on your behalf!
My signature and date in the box below authorizes each of the following:
1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to The Sensational Child Inc. and/or any of our corporate affiliates for medical supplies and/or medication(s) furnished to me by The Sensational Child Inc.
2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s).
Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurers and their agents and assigns.
3. The Sensational Child Inc. and/or any of our corporate affiliates to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided.
4. The Sensational Child Inc. and/or any of our corporate affiliates to contact me by telephone ormail regarding my medical supplies and/or medication(s) order.
I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible.
Patient Name*

First NameLast Name
Medicaid ID #*
If you do not know your Medicaid ID, call the DHS at 1-855-697-4345.
Medicare ID #
Leave blank if you do not have Medicare
Other Insurance Name*
Other Insurance ID #
Other Insurance Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Signature*
Name of Person Signing*

First NameLast Name
Relationship to Patient*
Ex: self, parent, guardian, etc.
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type a question
Should be Empty: