Auto Accident Insurance Claim Form

MENDELSON ORTHOPEDICS, P.C.


Injuries & Diseases of the Bones and Joints

Herbert Mendelson, M.D.
David H. Mendelson, M.D.
Jeffrey Mendelson, M.D.
Stephen Mendelson, M.D.
Martin Kornblum, M.D.
Alice Mendelson, M.D.

All fields are required.

Patient Name:

Patient Number:

DOB:

SSN:

Policy Holder:

Claim Number:

Insurance Billing Address:

Claim Adjuster's Name:

Claim Adjuster's Phone Number:

I hereby assign and direct

to pay by check, made out and mailed to:

MENDELSON ORTHOPEDICS, P.C.
14555 Levan Road, Suite 215
Livonia, MI 48154

or 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 IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. The 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 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 claim to my insurance company.

If applicable, I authorize Mendelson Orthopedics, P.C. to initiate a complain to the insurance Commissioner on my behalf.

Signature of Patient/Guardian:

Date:

Signature of Witness

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