Advanced Neurosurgery

Bulk Bill Assignment of Benefit Agreement
Patient Name:
Service Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit year
I assign my right to benefits to the practitioner who rendered (or will render) the medical service. I understand the practitioner will accept this benefit as a full payment for the service, and there will be no out-of-pocket cost to me.

By signing below, I authorise Medicare to pay Advanced Neurosurgery directly for the medical services provided.
Signature:
Agreement Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Should be Empty:

Bulk Bill Assignment of Benefit Agreement