Assignment of Insurance Benefits
I hereby instruct and direct my insurance company to pay for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered by check made out and mailed to Fern Creek Chiropractic Center, PSC, 6521 Bardstown Road, Louisville, KY 40291
If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it to Fern Creek Chiropractic Center, PSC, 6521 Bardstown Road, Louisville, KY 40291
I authorize the Doctor to deposit checks received on my account when made out to me.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above – mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.
I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.