Contact | Q & A | Topic | Free Ad    




Assignment of Benefits
This sample form may be used as a template to document when benefits should be assigned to a service provider. This is common when benefits are provided to a plan member and benefit payments are directed from the insurance company directly to the provider.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Assignment of Benefits TemplateForm 4039
Format: Word PDF
Category: Medical, Doctor Office
Type: Form

Assignment of Benefits

Date: ___/___/_____

PROVIDER INFORMATION :

[Providerís Name]

[Address]

[City, State Zip Code]

[Provider Registration #]

[Phone Number]

[Email Address]

Signature: ___________________________________

PLAN MEMBER INFORMATION :

[Plan Memberís Name]

[Address]

[City, State Zip Code]

[Plan Member ID #]

[Group ID #]

[Phone Number]

[Email Address]

AUTHORIZATION

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 Memberís Signature: _____________________________________Date: ___/___/_____