Neurosurgical Assignment of Benefits Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ SSN: ___________________________ Medical Record #: _________

Authorization Statement

I, the undersigned, authorize direct payment to [PRACTICE NAME] of any medical benefits otherwise payable to me for services rendered by the neurosurgical practice. I understand that I am financially responsible for all charges, whether or not paid by my insurance carrier.

Scope of Authorization

1. This assignment includes but is not limited to:

   • All medical insurance benefits
   • Medicare/Medicaid benefits
   • Personal injury protection benefits
   • Workers' compensation benefits

2. This assignment covers:

   • Professional fees
   • Technical components
   • Facility charges
   • Medical equipment/supplies

Financial Responsibility Agreement

I acknowledge and agree that:

• I am responsible for all co-payments, deductibles, and co-insurance
• Payment is due at the time of service
• I will be responsible for any costs associated with collection efforts
• A fee may be charged for missed appointments without 24-hour notice

Authorization Duration

This authorization shall remain in effect until revoked by me in writing.

Signatures

Patient Signature: _________________ Date: _______________

Witness Signature: _________________ Date: _______________

A copy of this assignment is considered as valid as the original