ASSIGNMENTS OF BENEFITS Clause Samples

ASSIGNMENTS OF BENEFITS. The Undersigned hereby certifies that all insurance information reported to Trinity Medical, WNY and all clinical providers for your care include all available sources of coverage, and assigns to the facilities of Trinity Medical, WNY, sufficient monies from said insurance to pay for the patient’s care and treatment. The Undersigned further understands that regardless of assignment of these benefits, the Undersigned is personally responsible for the total charges for services rendered, and further agrees that all amounts are due and payable upon demand. The Undersigned further agrees that Trinity Medical, WNY retain the right to transfer monies from any credit balance account in the Undersigned’s name to any other accounts which may be due and payable by the Undersigned FOR PATIENTS ENTITLED TO MEDICARE AND/OR MEDICAID BENEFITS: If applicable, I hereby irrevocably assign payment of Trinity Medical, WNY services and medical benefits applicable and otherwise payable to me to the designated Trinity Medical, WNY facilities and to all clinical providers providing care to me. I certify that the information provided in applying for payment under Title XVIII or XIX of the Social Security Act, is correct and request that payment of authorized benefits are made to the designated Trinity Medical, WNY facility and all clinical providers providing care on my behalf. The Undersigned authorizes any holder of medical or other information about the patient to release to the Social Security Administration and Centers for Medicare and/or Medicaid Services (CMS) or its intermediaries or carriers, any information needed for this or a related Medicare or Medicaid claim. The Undersigned assigns the benefits payable for physician services to the physician or organization furnishing the services or authorizes such physician or organization to submit a claim to Medicare or Medicaid for payment.