Benefit Assignment Form | Good Sign Massage

Instructions: This form must be filled out when claim payment is assigned to the Provider. Please retain this form in the patient’s file for verification purposes for two years following the closure of the patient file. If patients have one insurance company, no need to fill-out the secondary details.

Patient:*

First Last

Birthdate:

Mobile #:

Address:

Street Address City/Province: Postal Code:

Primary Coverage Information:

(Info about owner of the insurance.)

Relationship:

Insured Member
Spouse
Child
Handicapped Dependent
Domestic Partner

Primary Coverage Plan Member Name:*

Full Name

Birthdate:*

Insurance Name:

Policy/Group #:*

Certificate/Plan Member #:*

Secondary Coverage Plan Member Information:

(No need to fill-out if you have only one insurance.)

Relationship:

Insured Member
Spouse
Child
Handicapped Dependent
Domestic Partner

Secondary Coverage Plan Member Name:

Full Name

Birthdate:

Insurance Name:

Policy#/Group:

Certificate/Plan Member #:

Terms and Conditiions*

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in he event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an Assignment of benefit payments to the Provider.

I accept the Terms and Conditions

Signature

Date Signed

Email

This field is for validation purposes and should be left unchanged.