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United Collection Service, Inc.
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Assignment of Benefits

Our records show that the recipient of this letter received medical services from the provider indicated on the front of this form. If you have insurance, complete, sign and return this form so that we may file your insurance. Please be informed that there may by limitations on what carriers your provider will process claims for, you will be notified by a customer service representative should this be the case with your carrier.

PLEASE PROVIDE ALL INSURANCE INFORMATION YOU ARE REQUESTING TO BE BILLED BY THE PROVIDER, ALONG WITH A PHOTOCOPY FRONT AND BACK OF THE PROPER INSURANCE CARD.

Authorization

I authorize the Provider to release medical, psychiatric and substance abuse information contained in the patient's records to my insurance carrier for the purpose of obtaining payment, now and in the future. I assign payment directly to the Provider, the insurance benefits otherwise payable to me. I fully understand I am responsible to the provider for the changes not paid by this assignment.
*** PLEASE TYPE YOUR FULL NAME AND DATE. WE CANNOT FILE INSURANCE WITHOUT YOUR AUTHORIZATION. YOU CAN PRINT OUT THIS FORM AND FAX OR SCAN THE DOCUMENT AND SEND BY EMAIL AS WELL.

Download the form here

Request Follow Up

*This is a communication from a third party debt collector this is an attempt to collect a debt.*

Provider Outsource Service, Inc.
Make a Payment
Submit Insurance

Assignment of Benefits

Our records show that the recipient of this letter received medical services from the provider indicated on the front of this form. If you have insurance, complete, sign and return this form so that we may file your insurance. Please be informed that there may by limitations on what carriers your provider will process claims for, you will be notified by a customer service representative should this be the case with your carrier.

PLEASE PROVIDE ALL INSURANCE INFORMATION YOU ARE REQUESTING TO BE BILLED BY THE PROVIDER, ALONG WITH A PHOTOCOPY FRONT AND BACK OF THE PROPER INSURANCE CARD.

Authorization

I authorize the Provider to release medical, psychiatric and substance abuse information contained in the patient's records to my insurance carrier for the purpose of obtaining payment, now and in the future. I assign payment directly to the Provider, the insurance benefits otherwise payable to me. I fully understand I am responsible to the provider for the changes not paid by this assignment.
*** PLEASE TYPE YOUR FULL NAME AND DATE. WE CANNOT FILE INSURANCE WITHOUT YOUR AUTHORIZATION. YOU CAN PRINT OUT THIS FORM AND FAX OR SCAN THE DOCUMENT AND SEND BY EMAIL AS WELL.

Download the form here

Request Follow Up

Customer Service Center, Inc.
Make a Payment
Submit Insurance

Assignment of Benefits

Our records show that the recipient of this letter received medical services from the provider indicated on the front of this form. If you have insurance, complete, sign and return this form so that we may file your insurance. Please be informed that there may by limitations on what carriers your provider will process claims for, you will be notified by a customer service representative should this be the case with your carrier.

PLEASE PROVIDE ALL INSURANCE INFORMATION YOU ARE REQUESTING TO BE BILLED BY THE PROVIDER, ALONG WITH A PHOTOCOPY FRONT AND BACK OF THE PROPER INSURANCE CARD.

Authorization

I authorize the Provider to release medical, psychiatric and substance abuse information contained in the patient's records to my insurance carrier for the purpose of obtaining payment, now and in the future. I assign payment directly to the Provider, the insurance benefits otherwise payable to me. I fully understand I am responsible to the provider for the changes not paid by this assignment.
*** PLEASE TYPE YOUR FULL NAME AND DATE. WE CANNOT FILE INSURANCE WITHOUT YOUR AUTHORIZATION. YOU CAN PRINT OUT THIS FORM AND FAX OR SCAN THE DOCUMENT AND SEND BY EMAIL AS WELL.

Download the form here

Request Follow Up