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.

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Tom Lutz and Associates https://lutztherapy.com
Signature Certificate
Document name: Assignment of Benefits
Unique Document ID: cd4313ff7aa67b886197dbe1fd1847b4a50ee14f
Timestamp Audit
April 14, 2020 8:41 am CDTAssignment of Benefits Uploaded by Anne Hewitt - admin@lutztherapy.com IP 75.72.214.61
April 16, 2020 3:10 pm CDT Document owner justin@askdavinci.com has handed over this document to admin@lutztherapy.com 2020-04-16 15:10:38 - 174.53.135.153