|Magnolia Obstetrics and Gynecology, PLLC
3600 Gaston Ave. Barnett Tower Suite 601
Dallas, TX 75246-1806
OFFICE (214) 377-1699
LeAnn E. Haddock, MD, P.A Kamilia T. Smith, MD, P.A.
Assignment of Benefits and Release of Information
I, the undersigned, hereby assign the rights and benefits of the applicable medical payments to Magnolia Obstetrics and Gynecology, PLLC for the services and supplies rendered for my treatment. I understand and agree that this Assignment of Benefits will have continuing effect for so long as I am being treated or cared for by Magnolia Obstetrics and Gynecology, PLLC, and will constitute a continuing authorization, maintained on file with the Magnolia Obstetrics and Gynecology, PLLC, which will authorize and allow for direct payment to Magnolia Obstetrics and Gynecology, PLLC of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by Magnolia Obstetrics and Gynecology, PLLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this statement is to be considered as valid as an original.
I hereby authorize Magnolia Obstetrics and Gynecology, PLLC to release any and all medical records including medical, surgical, psychiatric, substance abuse, HIV and genetic information which may be found within the records needed to secure payment or determine benefits from insurance payers and other third party administrators. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not paid by said insurance.
I have read and understand the Assignment of Benefits and Release of Information policies contained herein.
Print Name: ________________________________________ Date _________________
Patient Signature: ____