ASSIGNMENT AND RELEASE I certify that I have insurance coverage with Name of Insurance Company(ies)...

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Transcript of ASSIGNMENT AND RELEASE I certify that I have insurance coverage with Name of Insurance Company(ies)...

Page 1: ASSIGNMENT AND RELEASE I certify that I have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to
Page 2: ASSIGNMENT AND RELEASE I certify that I have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to