Office: New Patient Forms
Assignment of Benefits
PAYMENT TO DOCTOR
(Under California State Insurance Code 10133*)
I hereby authorize _________________________________________
Insurance Company to pay by check made out
to and mailed directly to Andrew Kochan, M.D.
for medical expense benefits allowable, and
otherwise payable to under my current insurance
policy, as payment towards charges for professional
services rendered. This payment will not exceed
my indebtedness to the above-mentioned assignee
and I have agreed to pay, in a current manner,
any balance of said professional service charges
over-and-above this insurance payment. A photocopy
of this authorization shall be considered as
effective and valid as the original.
* This office
holds an assignment/lien on this case for services
rendered. Any settlement of this claim without
honoring assignment/lien will cause you to be
responsible to this office for immediate payment.
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