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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Document Name: ASSIGNMENT OF BENEFITS
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