ASSIGNMENTS OF BENEFITS. The Undersigned hereby certifies that all insurance information reported to all facilities of CHS and all clinical providers for this episode of care include all available sources of coverage, and assigns to the facilities of CHS, sufficient monies from said insurance to pay for the patient’s care and treatment. The Undersigned further understands that regardless of assignment of these benefits, the Undersigned is personally responsible for the total charges for services rendered, and further agrees that all amounts are due and payable upon demand. The Undersigned further agrees that the facilities of CHS retain the right to transfer monies from any credit balance account in the Undersigned’s name to any other accounts which may be due and payable by the Undersigned FOR PATIENTS ENTITLED TO MEDICARE AND/OR MEDICAID BENEFITS: If applicable, I hereby irrevocably assign payment of all CHS services and medical benefits applicable and otherwise payable to me to the designated CHS facilities and to all clinical providers providing care to me. I certify that the information provided in applying for payment under Title XVIII or XIX of the Social Security Act, is correct and request that payment of authorized benefits are made to the designated CHS facility and all clinical providers providing care on my behalf. The Undersigned authorizes any holder of medical or other information about the patient to release to the Social Security Administration and Centers for Medicare and/or Medicaid Services (CMS) or its intermediaries or carriers, any information needed for this or a related Medicare or Medicaid claim. The Undersigned assigns the benefits payable for physician services to the physician or organization furnishing the services or authorizes such physician or organization to submit a claim to Medicare or Medicaid for payment.
ASSIGNMENTS OF BENEFITS. I hereby authorize ADVANCED ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS, P.C. to release necessary medical information to my insurance carrier to pay any benefits directly to ADVANCED ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS, P.C.
ASSIGNMENTS OF BENEFITS. The Undersigned hereby certifies that all insurance information reported to the hospitals of CHS for this episode of care include all available sources of coverage, and assigns to the hospitals of the CHS, sufficient monies from said insurance to pay for the patient’s care and treatment. The Undersigned further understands that regardless of assignment of these benefits, the Undersigned is personally responsible for the total charges for services rendered, and further agrees that all amounts are due and payable upon demand. The Undersigned further agrees that the hospitals of CHS retain the right to transfer monies from any credit balance account in the Undersigned’s name to any other accounts which may be due and payable by the Undersigned.
ASSIGNMENTS OF BENEFITS. In consideration of services rendered or to be rendered, I hereby assign and transfer any benefits otherwise payable to me for my benefit under hospitalization, health or accident insurance, and other insurance coverage, to include major medical benefits, for the payment of services rendered. If a MEDICARE patient, I certify that the information given by me in applying for payment under TITLE XVII of the Social Security Act is correct. I request that payment of authorized benefits may be made on my behalf. (Signature of parent/guardian or camper, if own guardian) Date Printed Name
