Assignment of Benefits for the Treatment of a Minor
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Client Name: Client Date of Birth:
Parent or Guardian Signing this Form:
I hereby assign payment of insurance benefits on my child/children’s behalf to include major medical benefits to Tom Lutz and Associates and to release any medical information deemed necessary to secure payment. I understand that if I have insurance coverage, but do not give the necessary information needed for billing purposes, I will be responsible for 100% of the charges I incur for the treatment of my child(ren).
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Document Name: Assignment of Benefits for the Treatment of a Minor
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