Assignment of Benefits to Harvest Physical Therapy DBA One Accord Physical Therapy
This is a direct assignment of my rights and benefits under this policy.
Harvest Physical Therapy
1377 E. Florence Blvd. Ste. 151-L5
Casa Grande, AZ 85122
If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and Harvest Physical Therapy and mail it to the above address for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the 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 Assignment shall be considered as effective and valid as the original.
• I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or
attorney involved in this case for the purpose of processing claims and securing payment.
• I authorize the use of this signature on all insurance submissions.
• I authorize Harvest Physical Therapy to deposit checks made in my name.
• I authorize Harvest Physical Therapy to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
• I understand that I am financially responsible for all charges whether or not paid by insurance.