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
TO :
Insurance Company
RE : Insured Claim #
Accident/Work Comp Only
Policy # Please Check One :
FOR HEALTH INSURANCE ONLY Assignment is hereby made as to the medical payment on the above policy to be paid directly to The Center For Advanced Orthopedics, PA.
Payment should be made 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. 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.
Date
Patient/Parent (if minor)
FOR AUTOMOBILE ACCIDENTS/WORKERS COMPENSATION ONLY : Date of Accident : Assignment is hereby made as to the PIP benefits and/or medical payment on the above policy to be paid directly to The Center For Advanced Orthopedics, PA.
Payment should be made 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 accident to the extent of my coverage. I agree that I will use my PIP Coverage and/or 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.
Date :
Patient/Parent (If minor)