Insurance Benefits Assignment Consent Form

Patients confirm their plan details and allow the clinic to bill their insurer directly. Primary and secondary coverage fields capture member names, policy numbers, and certificate numbers. Helpful for dental practices, clinics, and therapy offices.

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Full name

Nombre

Apellido

Primary coverage insurer or payer name

Nombre

Apellido

Primary coverage plan member name

Nombre

Apellido

Primary coverage policy number (also called group or contract number)

Primary coverage certificate (also called member or identification number)

Secondary coverage plan member name, if applicable

Assignment of benefits

Authorization and consent

Date

Signature

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