Assignment of Benefits
1320 South Frontage Road, Suite 200 Hastings, MN 55033-2481 651-500-0905 651-437-2616 fax LutzTherapy.com
Adult Assignment of Benefits
Client Name: Client Date of Birth:
I hereby assign payment of insurance benefits 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.
Leave this empty:
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Assignment of Benefits
Agree & Sign