Assignment of Insurance Benefits

Patient Name*

Date of Birth

Address

City

State

Zip Code

Health Insurance

ID Number

Group Number

Secondary Insurance (if applicable)

D Number

Group Number

Auto/Work Injury

Insurance Company

Date of Injury

Policy Number

Claim Number

I hereby authorize Daniel O. Cook, D.C. to furnish my insurance company all information, which it requests, concerning my present claim. I assign to Daniel O. Cook, D.C. all money to which I am entitled for all services that they have performed related to this claim. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. It is understood that any money received by Daniel O. Cook, DC that exceeds my indebtedness to Daniel O. Cook, D.C. will be fully refunded to me when my bill is paid in full. I understand that I am financially responsible and liable for any expenses that are not reimbursed by my insurance company.

I hereby instruct and direct ______________________________________________ Insurance Company to pay by check, made out and mailed to: Daniel O. Cook, D.C., 1765 State St. Salem, OR 97301.

If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it as follows

C/O Daniel O. Cook, D.C., 1765 State St. Salem, OR 97301.

A photocopy of this Agreement shall be considered as effective and valid as the original.
I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Signature of Policyholder

Date

Signature of Claimant, if other than Policyholder

Date

Please do not submit any Protected Health Information (PHI).

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Health Insurance

Auto/Work Injury

DC Chiropractic Center

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