Assignment of Benefits for the Treatment of a Minor


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Assignment of Benefits for the Treatment of a Minor

 

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).

Leave this empty:

Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Assignment of Benefits for the Treatment of a Minor
Unique Document ID: edddee19ff7573d8db01c8a762e27ae9c24e52b4
Timestamp Audit
April 15, 2020 10:18 pm CDTAssignment of Benefits for the Treatment of a Minor Uploaded by Anne Hewitt - admin@lutztherapy.com IP 75.72.214.61
April 16, 2020 3:08 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:08:32 - 174.53.135.153