ASSIGNMENT OF BENEFITS
I agree to and authorize treatment as deemed necessary by TransSouth Health Care, P.C. If your
injury or illness is work related or accident related, please advise the receptionist.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I
am entitled to TransSouth Health Care, P.C. If I hold Medicare and/or Medigap Insurance, I
request payment of authorized benefits be made on my behalf to TransSouth Health Care, P.C.
for any services furnished to me.
This assignment will remain in effect until revoked by me in writing. A photocopy of this
assignment is to be considered as valid as an original. I understand that I am financially
responsible for all allowed charges and/or co-payments whether or not they are paid by my
insurance. I hereby authorize said assignee to release all information necessary for
determination of benefits to my insurer or the Healthcare Financing Administration.
In the event that I am denied coverage, I will make arrangements to pay all bills within 30 days.
Signature ______________________________________
Date _______________________