Print This Form
Assignment of Benefits
Name:
Address:

Phone #:
DOB:
 
Medicare #: ______________________________________

Primary Insurance:
(Social Security # and/or Policy #: ___________________________________________
Name of Insurance Company

 

__________________________________                           __________________
Beneficiary                                                                               Date

 

I request that payment of authorized Medicare/Insurance benefits be made on my behalf to Women's Health Boutique for any services furnished to me by that provider. I authorize any holder of medical information concerning me to be released to Women's Health Boutique, or to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

Women's Health Boutique assumes unconditional responsibility for refunding any overpayments that are made by the Medicare/Insurance Carrier.

 

 

____________________________________          __________________________________
Signature of Beneficiary                                               Women's Health Boutique