Patient:
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Employer:
Claim/Group:
SS#/ID#:
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I hereby instruct and direct that
Insurance Company to pay by check made out and mailed to:
Neubauer Hyperbaric Center4001 Ocean Dr., Suite 105 Lauderdale-by-the-Sea, FL. 33308
If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows:
c/o Neubauer Hyperbaric Center 4001 Ocean Dr., suite 105 Lauderdale-by-the-Sea, FI. 33308
The professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to be 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. A photocopy of this assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.
Dated at:
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Signature of Policy Holder
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Signature of Claimant if other than policyholder
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INSURANCE INFORMATION
NAME OF INSURED (GUARANTIOR)
DOB of Insured
Primary Insurance
Contact Phone #
Primary Address
City
State
Zip
Secondary Insurance
Secondary ID#
Secondary Grp#
Secondary Phone
Secondary Contact
Secondary Address
City
State
Zip
Submit
Should be Empty: