Assignment Of Medicare Benefits - Columbus Eye Associates printable pdf download

Assignment Of Medicare Benefits - Columbus Eye Associates

ASSIGNMENT OF MEDICARE BENEFITS

PATIENT NAME:__________________

MEDICARE NUMBER : ____________________________

I request that payment of authorized Medicare benefits be made on my behalf to

COLUMBUS EYE ASSOCIATES

For any service furnished to me by a physician of the group. I authorize any holder of

medical information about me to release to the Health Care Financing Administration and

its agents any information needed to determine these benefits payable for related services.

In Medicare assigned cases, the provider agrees to accept the charge determination of the

Medicare carrier and I am responsible for the Medicare deductible, co-insurance or the

20% Medicare does not pay, and for any non-covered services.

My signature below further verifies that I have not joined an HMO or other entity in

which my Medicare benefits have been relinquished.

SIGNATURE: ________________________________________________

DATE: ___________________________

MEDIGAP OR OTHER SECONDARY INSURANCE

I request that the payment of authorized Medigap benefits be made either by me or on my

behalf to COLUMBUS EYE ASSOCIATES, or any physician of that group, for

services provided to me by a physician of the group. I authorize any holder of medical

information about me to release it to my Medigap insurer, ____________, or any

information needed to determine these benefits for related services.

The assignment shall remain in effect until revoked by me in writing. A photocopy of this

assignment is considered as valid as the original.

SIGNATURE: ________________________________________________

DATE:______________________________

Assignment Of Medicare Benefits - Columbus Eye Associates