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I hereby understand that the fees that are listed in this claim may not be covered by or may indeed exceed all of my plan benefits. I also
understand that I alone am financially responsible to the service provider for all of the cost that is associated with this claim and I do
hereby assign my benefits payable from this claim to the above named service provider and I authorized payment directly to them.
I fully understand that the Benefit Plan Sponsor has the right to modify the assignment privileges for specific benefits, categories and or
service provider categories.
I hereby certify that all of the information that is provided in connection with this claim is true, complete and accurate. I authorize any
doctor, medical practitioner, or any other person that may have any records, knowledge or information regarding this claim to release such
information and to exchange information with any of the named parties where the exchange is necessary for the proper processing of the
claim. All photo copies of this signed Assignment of Benefits shall be as valid as the original.
Plan Member’s Signature: _____________________________________Date: ___/___/_____
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