Center For Advanced Orthopedics Assignment of Benefits FORM

CENTER FOR ADVANCED ORTHOPEDICS, PA SHAHEER YOUSAF, M.D., F.A.C.S. DIPLOMATE AMERICAN BOARD OF ORTHOPEDIC SURGEONS CHARLES (301) 645-5410 HOLLYWOOD (301) 373-4303 D.C. LINE (301) 843-7663 FAX (301) 645-7680 Assignment is hereby made as to the medical... More

CENTER FOR ADVANCED ORTHOPEDICS, PA SHAHEER YOUSAF, M.D., F.A.C.S. DIPLOMATE AMERICAN BOARD OF ORTHOPEDIC SURGEONS CHARLES (301) 645-5410 HOLLYWOOD (301) 373-4303 D.C. LINE (301) 843-7663 FAX (301) 645-7680 Assignment is hereby made as to the medical payment on the above policy to be paid directly to The Center For Advanced Orthopedics, PA. You are hereby authorized to make direct payment to this healthcare provider for treatment rendered for the above injury to the extent of my coverage. Date Please Check One : Payment should be made directly to The Center for Advanced Orthopedics, PA I agree that I will use my medical payment to pay medical bills for services rendered to this healthcare provider. I agree that I will not specify payment to other physicians as a priority over this practice. Patient/Parent (if minor) FOR HEALTH INSURANCE ONLY FOR AUTOMOBILE ACCIDENTS/WORKERS COMPENSATION ONLY : Date of Accident : Assignment is hereby made as to the PIP benefits and/or medical payment on Less