Assignment of Benefits

I hereby assign to Form Health Associates (MA), P.C., a Massachusetts professional corporation or Form Health Associates, P.C., a California medical corporation (collectively, “Form Health”), as applicable, all my right, title, and interest in any and all health insurance or other health care benefits payable to me or on my behalf by any insurance payer, including Medicare, private insurance and any other health plan for medical treatment rendered by Form Health.  The assignment will remain in effect until revoked by me in writing.  I authorize the release of pertinent information necessary to process my medical claim.  I also authorize direct payment to Form Health of all insurance benefits payable to me for such medical treatment.  In the event an insurance payer pays me directly, I agree to immediately pay such amounts to Form Health.  

I understand that my insurance payer may pay less than the actual bill for services.  I acknowledge that I am still responsible for paying Form Health for any and all amounts not paid by my insurance payer, including non-covered charges (in accordance with an applicable patient financial responsibility agreement) and all copayments, coinsurance, and deductibles.  I understand that if my insurance requires a referral, I am responsible for obtaining one prior to my appointment.  In the event any collection action is necessary to collect amounts I owe to Form Health, I agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees. 

□ ACCEPT. By checking the Box for this "ASSIGNMENT OF BENEFITS FORM" I hereby certify that I have read, understand, and agree to the foregoing and received a copy thereof.  I am the patient, the patient’s legal representative, or am otherwise duly authorized by the patient to sign the above and accept its terms on his/her behalf.