Assignment and Release

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Full name: First, Middle, Last

I understand and agree that (regardless of whatever health or medical benefits I have), I am ultimately responsible to pay Youngstown Spine & Disc, LLC., the balance due on my account for any professional services rendered for any supplies, tests, or medications provided.
*

Yes

I hereby authorize payment of any health insurance or medical plan benefits directly to Youngstown Spine & Disc LLC., for medical services rendered and for any supplies, tests or medications provided.
*

Yes

I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with the same.
*

Yes

I hereby assign directly to Youngstown Spine & Disc, LLC., all rights to payments and benefits and all legal and other health plans that I (or my child, spouse or minor dependant) may have under my/our applicable health plan(s) or health insurance policy(ies).
*

Yes

This assignment includes, but is not limited to, a designation that Youngstown Spine & Disc, LLC. can act on my/our behalf, as our representative or ERISA representative, as to any initial claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and/or payments that are due to Youngstown Spine & Disc, LLC., as a result of services rendered by Youngstown Spine & Disc, LLC., and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan or insurer.
*

Yes

This assignment and designation remains in effect unless revoked in writing, and a photocopy is to be considered as valid and enforceable as the original.

Yes

Today's date

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms