Assignment of Benefits
Patient Name
Home Phone
Insurance ID No.
Group No.
I,
understand that services rendered to me by
South Florida Neurology Associates, PA
are my financial responsibility and that the provider will bill my insurance company
as a courtesy. I authorize my insurance company to pay my benefits directly to
South Florida Neurology Associates, PA
and I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.
I have been given the opportunity to pay my estimated deductible and coinsurance at the time of service. I have chosen to assign the benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by
(insurance company).
I authorize the provider to release any information necessary to adjudicate the claim, and understand that there may be associated costs for providing information beyond what is necessary for the adjudication of a clean claim.
I also understand that should my insurance company send payment to me, I will forward the payment to
South Florida Neurology Associates, PA
within 48 hours. I agree that if I fail to send the payment to
South Florida Neurology Associates, PA
and they are forced to proceed with the collections process; I will be responsible for any cost incurred by the office to retrieve their monies. In the event patient receives any check, draft or other payment subject to this agreement, I will immediately deliver said check, draft or payment to provider. Any violations of this agreement will, at provider’s election, terminate patient charge privileges with provider and bring any balance owed by patient to provider immediately due and payable.
I authorize the provider to initiate a complaint or file appeal to the insurance commissioner or any payer authority for any reason on my behalf and I personally will be active in the resolution of claims delay or unjustified reductions or denials.
Patient/Guardian/Policyholder Signature
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