Oncology Assignment of Benefits Agreement

Patient Information

Name: _________________________ Date of Birth: __________________ Medical Record #: _______________

Insurance Information

Primary Insurance: ______________ Policy #: ______________________ Group #: ______________________

Assignment of Benefits Declaration

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above-named insurance company and assign directly to [ONCOLOGY PRACTICE NAME] all insurance benefits, if any, otherwise payable to me for services rendered.

Authorization Terms

1. I authorize the release of all medical information necessary to process insurance claims.
2. I authorize the use of this signature on all insurance submissions.
3. I understand I am financially responsible for all charges whether paid by insurance.
4. I authorize [ONCOLOGY PRACTICE NAME] to submit claims on my behalf.
5. I authorize payment of medical benefits directly to [ONCOLOGY PRACTICE NAME].

Treatment Authorization

I hereby authorize [ONCOLOGY PRACTICE NAME] and its affiliated physicians to provide medical treatment, including but not limited to:

• Chemotherapy administration
• Radiation therapy
• Diagnostic procedures
• Related oncology services

Duration and Revocation

This assignment will remain in effect until revoked by me in writing.

Signatures

Patient/Guardian Signature: _________________________ Date: ________________

Witness Signature: ________________________________ Date: ________________

Practice Information

[PRACTICE NAME] [ADDRESS] [PHONE] [FAX] [LICENSE/NPI]