Benefit Assignment Form

  • 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.
  • MM slash DD slash YYYY
  • Primary Coverage Information:

  • MM slash DD slash YYYY
  • Secondary Coverage Plan Member Information:

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