BOH Agenda 082620 - Laserfiche WebLink

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Board of Health P&P Manual,Section I Policy E,Attachment E Assignment of Benefits Client Name (Last,First,Middle Initial) Date of Birth(DOB) Insurance Provider Client's Insurance ID# Subscriber's Name Subscriber's DOB Policy# Subscriber's Address(If different from client) Subscriber's phone# I authorize Orange County Health Department to file insurance claims for services provided to me. These claims may be filed with Medicare,Medicaid,private insurance,or any other medical/dental plan. I understand that it is my responsibility to report any changes in insurance coverage. I understand that I am financially responsible for any amount not covered by insurance,unless otherwise stated in the provider agreement. I understand that any co-payment or deductible is due at the time that services are rendered. If insurance coverage is denied,I understand that I will be responsible for all charges for these services. I understand that I may be eligible for the sliding fee scale,based on residency and income, if I provide verification within 10 business days of being notified. I authorize the release of any medical or pertinent information necessary to obtain these benefits to my insurance carrier or any other medical entity for continued medical care. Please state any records you want excluded from information that may have to be released: Client Signature Date Interpreter Signature Date OCHD Employee Signature/Witness Date S:\MANAGERS WORKING FILES\BOH\Policies and Procedures\BOH Policy Manual\Current Policy Manual\I.E.Attachment E-Assign of Benefits.docx Updated 11/2014 919 245 2400 ) 300 West Tryon Street ) Hillsborough, NC 27278 1 orangecountync.gov