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Direct Payment Form

ASSIGNMENT AND INSTRUCTIONS FOR DIRECT PAYMENT

I hereby instruct and direct the

Insurance Company to pay by check made out to :

FINALLY HEALTH MEDICAL SERVICES, P.C.

3500 Nostrand Ave
Brooklyn, NY 11229

If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows :

See Above Address

The payment is to be the complete professional and / or medical expense allowable, and otherwise payable to me under my current insurance policy as payment towards the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. 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 photo copy of this Assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

By submitting, the co-payment of my treatment would be a financial hardship on me.

Verification Code