Assignment of Benefits

1320 South Frontage Road, Suite 200  Hastings, MN  55033-2481
651-500-0905   651-437-2616 fax

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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Document name: Assignment of Benefits
lock iconUnique Document ID: 924911f8dcce474e7e401d0b5d370d70ea0977d4
Timestamp Audit
April 14, 2020 8:41 am CDTAssignment of Benefits Uploaded by Anne Hewitt - IP
April 16, 2020 3:10 pm CDT Document owner has handed over this document to 2020-04-16 15:10:38 -