Assignment Of Benefits Form

Medicare Beneficiaries

Assignment of Benefits

Once the deductible is met, Medicare pays 80% of the

remaining reasonable charges

I understand that Medicare pays for 80% of the allowable charges and that I am

responsible for all remaining balances not covered by Medicare. I certify that the

information provided in applying for payment under Title XVIII of the Social

Security Act is correct. I authorize the release of any information needed to act

on this request. I request that the payment of authorized benefits be made

directly to the provider – [provider name here] (Tax ID—XXX) on my behalf.

_________________________________________

Client’s Signature

Date

_________________________________________

Witness (if needed)

_________________________________________

Mother/Guardian Signature

Date

_________________________________________

Father/Guardian Signature

Date

*Please note the insured parent signature is required

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Parent category: Business