Assignment of Benefits

 

INSURANCE (NOT MEDICARE)

By filling out my name and checking the box below, I authorize my insurance company to pay benefits on my behalf directly to North Metro Dermatology. I authorize North Metro Dermatology to provide to my insurance company, any information necessary to process claims for services rendered to me.


 

MEDICARE

By filling out my name and checking the box below, I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.


 

ADDITIONAL COVERAGE OR SECONDARY INSURANCE

If you have a supplemental policy and it is a policy to which your Medicare Carrier automatically “crosses over”, we are required to keep a separate signature on file:

 

By filling out my name and checking the box below, I request authorized benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to my carrier any information needed to determine these benefits or the benefits payable for related services.

Customized by Amanda O'Brien Design