Release of Information and Assignment of Benefits for Insurance CompaniesClient Name(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Person Financially Responsible(Required) First Last Primary Insurance Company Name(Required) Subscriber ID(Required) Policy holder's name(Required) First Last Policy holder's date of birth(Required) MM slash DD slash YYYY Add a secondary insurance company?(Required) Yes No Secondary Insurance Company Name(Required) Secondary Insurance Subscriber ID(Required) Secondary Insurance Policy holder's name(Required) First Last Secondary Insurance Policy holder's date of birth(Required) MM slash DD slash YYYY Add a tertiary insurance company?(Required) Yes No Tertiary Insurance Company Name(Required) Tertiary Insurance Policy holder's name(Required) First Last Tertiary Insurance Policy holder's date of birth(Required) MM slash DD slash YYYY Address of Policy holder(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorization of release of information(Required) I authorize the release of any medical or other information (including psychiatric, HIV and drug and/or alcohol related) necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. Client or authorized person's signature(Required) Signature date(Required) MM slash DD slash YYYY Authorization of payment(Required) I authorize payment of medical benefits to the assigned physician or supplier for services provided at Child & Family Agency of Southeastern Connecticut, Inc. Client or authorized person's signature(Required) Signature date(Required) MM slash DD slash YYYY
