Forms – Release of Information and assignment of benefits for insurance companies

Release of Information and Assignment of Benefits for Insurance Companies

Client Name(Required)

First Last

Client Date of Birth(Required)

Person Financially Responsible(Required)

First Last

Primary Insurance Company Name(Required)

Subscriber ID(Required)

Policy holder's name(Required)

First Last

Policy holder's date of birth(Required)

Add a secondary insurance company?(Required)

Yes

Secondary Insurance Company Name(Required)

Secondary Insurance Subscriber ID(Required)

Secondary Insurance Policy holder's name(Required)

First Last

Secondary Insurance Policy holder's date of birth(Required)

Tertiary Insurance Company Name(Required)

Tertiary Insurance Policy holder's name(Required)

First Last

Tertiary Insurance Policy holder's date of birth(Required)

Address of Policy holder(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Authorization of release of information(Required)

I authorize the release of any medical or other information (including psychiatric, HIV and drug and/or alcohol related) necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.

Client or authorized person's signature(Required)

Signature date(Required)

Authorization of payment(Required)

I authorize payment of medical benefits to the assigned physician or supplier for services provided at Child & Family Agency of Southeastern Connecticut, Inc.

Client or authorized person's signature(Required)

Signature date(Required)