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

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

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