If you have checked Yes to any of the above, please provide...
If you are covered by Medicare, or any other basic hospitalization or surgical plan such as Blue Cross-Blue Shield, please submit these carrier’s payment statements or declinations along with itemized bills.
Complete For Injury Or Illness
If Claim For Dependent, Complete This Section Also
Important – Please Complete Authorization Section
The above answers are true and correct to the best of my knowledge. I hereby authorized any physician, surgeon, practitioner or other person, any hospital, including veterans administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release to each other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A Photostat of this authorization shall be as valid as the original.
I hereby assign my rights to benefits (including all rights arising under § 514(a) of ERISA, 29 U.S.C. §1144(a)) to, and authorize payment directly to, the Physician named above for those benefits to which the Plan Member is entitled, provided the benefits paid do not exceed the Physician’s regular charges. I understand I am financially responsible to the Physician for charges not covered by this assignment.