drbechererandassociates.com - Assignment of Benefits

ASSIGNMENT OF BENEFITS/INSURANCE RELEASE
Primary Medical Insurance

(Policy Holder’s Information Only)
Name of Insurance
Policy/Member #
Group #
Please select
(NOTICE: HMO REQUIRE REFERRAL)
Name of Policy Holder
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Relationship to Patient
Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Medical Insurance

(Policy Holder’s Information Only)
Name of Insurance
Policy/Member #
Group #
Please select
(NOTICE: HMO REQUIRE REFERRAL)
Name of Policy Holder
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Relationship to Patient
Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vision Insurance

(Policy Holder’s Information Only)
Name of Vision Insurance
Name of Policy Holder
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
ID or Social Security #
Primary Care Physician’s Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Fax#
Prescription Refills
If you are taking medications prescribed by one of our doctors and you need a refill, please call your pharmacy first. Your pharmacy will fax over a refill request. We ask that you allow 3 business days for processing your request. Make sure you call your refill in while you still have a few days of medication remaining to get through until the prescription can be processed. My signature below authorizes the office of Dr. Becherer & Associates, LTD. to fax/ERX prescriptions to any pharmacy.
Name of Pharmacy
Phone/Fax #
Patient/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Responsibility Statement and Notice of Privacy Policy
I, Patient Name , understand that I am being seen by Dr. Becherer & Associates, LTD and they will bill my primary insurance based on the information I provided above.

The filing of a claim for any service rendered DOES NOT GUARANTEE PAYMENT from your insurance company. Billing to secondary insurance is not a service we provide; it is up to the patient to make sure claims are sent to secondary if they want them to pay a portion of the services. I understand that if my information provided above is incorrect, or I did not obtain the proper referral when required, I will be financially responsible for payment of all charges incurred for services and/or materials received. I authorize release of medical information necessary to process insurance claims and payments of medical/vision benefits when requested by the insurance company. If any insurance is used and there are additional fees or charges owed, one billing statement will be sent at no charge. EACH ADDITIONAL STATEMENT WILL BE $5.00.

I acknowledge that I have read the Notice of Private Policy for Dr. Becherer & Associates, LTD.
Patient/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

ASSIGNMENT OF BENEFITS/INSURANCE RELEASE

Primary Medical Insurance

Secondary Medical Insurance

Vision Insurance

Primary Care Physician’s Information

Prescription Refills

Patient Responsibility Statement and Notice of Privacy Policy