Assignment Of Benefits Form printable pdf download

Assignment Of Benefits Form

Chart Number: _____________

Assignment of Benefits Form

I hereby authorize my insurance benefits to be paid directly to CHAPA-DE INDIAN

HEALTH PROGRAM, INC. I am financially responsible for non-covered services. I

also authorize CHAPA-DE to release to my insurance company, Medicare or Medi-Cal

any information required to process this claim (including information relating to alcohol,

drug abuse and mental/nervous disorders).

I authorize Chapa-De Indian Health Program, Inc. to provide medical, dental, and/or

behavioral health care to the minor named below as a patient or to myself. I have read

and understand the Patient Bill of Rights.

Patient’s Name: _______________________________________________________

Signature: ___________________________________ Date: ____________________

Patient/Guardian/Authorized Representative

Relationship: __________________________________________________________

Auburn Health Center 11670 Atwood Road Auburn, CA 95603 (530) 887-2800

Grass Valley Health Center 1350 East Main Street Grass Valley, CA 95945 (530) 477-8545

Assignment Of Benefits Form