DIRECT 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.

Date______

Name ______________________

Signature ______________________

Address ______________________

                ______________________

* 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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• Virtual Office
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    • Private insurance
    • Medicare
  • New Patient Forms
    • New Patient information
    • Insurance information
    • Medical history
    • Release of information
    • Medicare form
    • Notice of Privacy Practices
    • Assignment of Benefits