"Medicare Beneficiaries Assignment of Benefits Form"

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Medicare Beneficiaries
Assignment of Benefits
Once the deductible is met, Medicare pays 80% of the
remaining reasonable charges
I understand that Medicare pays for 80% of the allowable charges and that I am
responsible for all remaining balances not covered by Medicare. I certify that the
information provided in applying for payment under Title XVIII of the Social
Security Act is correct. I authorize the release of any information needed to act
on this request. I request that the payment of authorized benefits be made
directly to the provider – [provider name here] (Tax ID—XXX) on my behalf.
_________________________________________
Client’s Signature
Date
_________________________________________
Witness (if needed)
_________________________________________
Mother/Guardian Signature
Date
_________________________________________
Father/Guardian Signature
Date
*Please note the insured parent signature is required
Medicare Beneficiaries
Assignment of Benefits
Once the deductible is met, Medicare pays 80% of the
remaining reasonable charges
I understand that Medicare pays for 80% of the allowable charges and that I am
responsible for all remaining balances not covered by Medicare. I certify that the
information provided in applying for payment under Title XVIII of the Social
Security Act is correct. I authorize the release of any information needed to act
on this request. I request that the payment of authorized benefits be made
directly to the provider – [provider name here] (Tax ID—XXX) on my behalf.
_________________________________________
Client’s Signature
Date
_________________________________________
Witness (if needed)
_________________________________________
Mother/Guardian Signature
Date
_________________________________________
Father/Guardian Signature
Date
*Please note the insured parent signature is required
Assignment of Benefits
In order for us to bill Medicaid and/or other insurance for your medical
supply(s), this form must be completed, signed and returned immediately.
• I, the undersigned, hereby authorize assignments of and direct billing to
Medicaid and/or other insurance benefits to [name of company] for
supplies furnished to me.
• I further agree and acknowledge that my signature on this document
authorizes [name of company] to obtain and release any medical and
billing information to Medicaid and/or other insurers necessary to process
my claim(s), including determining eligibility and seeking reimbursement
for supplies provided.
• I request that payment of authorized benefits be made to [name of
company] on my behalf, for supplies furnished to me.
• I will be responsible for my insurance deductible.
• If my insurance company reimburses me directly instead of [name of
company], I will submit payment in the same amount to them.
Print Patient's Name
_______________________________________________________
Patient’s Signature
________________________________________________________
Guardian Signature
_______________________________________________________
Date
______________________
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