Assignment of Benefits Form

 
Financial Responsibility

All professional services rendered are charged to the patient and are due at time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for our insurance carrier payments.

Assignment of Benefits

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, automobile insurance and any other health/medical plan, to issue payment check(s) directly to Rehabilitation Chiropractic Care for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand I am responsible for any amount not covered by insurance.