Assignment of Benefit-Release of Information
We will bill your insurance carrier solely as a courtesy to you. If any payment is made directly to you for services billed by us, you recognize an obligation to promptly remit same to Dr. Benjamin Agana.
By submitting this form I hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance and third-party payors to Dr. Benjamin T. Agana.
I hereby author rise the said assignee to release all information necessary, including medical records to secure payment.