ASSIGNMENT OF BENEFITS


We require insured patients to complete assignment of benefits authorizing insurance to remit payment to physician’s office.

I hereby assign all medical and/or surgical benefits to include major medical benefits, to which I am entitled, by private insurance or any other health plan to:  Gastroenterology and Hepatology Institute of Nevada.  This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.  I understand that I am financially responsible for all charges not paid by said insurance.  I hereby authorize said assignee to release all medical information necessary to secure the payment.

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Rajat Sood M.D. http://www.rajatsood.com
Signature Certificate
Document name: ASSIGNMENT OF BENEFITS
lock iconUnique Document ID: 4f3b3368a34b4d5b9b12d73ace27f2a87412a319
Timestamp Audit
April 21, 2020 3:11 am PDTASSIGNMENT OF BENEFITS Uploaded by Rishawn Newman - rnewman@rajatsood.com IP 68.96.239.191