Insurance Company Name
Insurance Claim Address
City, State, Zip
Insurance company phone
ID Number Group Number
Employer
First Name MI Last Name
Insurance Company Name
Insurance Claim Address
City, State, Zip
Insurance company phone
ID Number Group Number
Employer
First Name MI Last Name
ASSIGNMENT OF BENEFITS AND AUTORIZTION TO REALASE INFORMATION
I hereby authorize payment directly to provider of services for which benefits are payable. I herby authorize the release of pertinent medical information to my insurance carries.
Signature: Date: