~ ASSIGNMENT OF BENEFITS ~
With execution of this instrument the undersigned, in consideration for services rendered or
to be rendered by Kentucky Diagnostic Center:
Patient Name: (Please Print)
Edgewood Alexandria Hebron
1. Assigns all monies due to insured from insurer under the attached claim to Kentucky
2. Serves notice to insurer of the preceding assignment
3. Orders insurer to pay to Kentucky Diagnostic Center all monies due to insured under the
4. Acknowledges that this assignment does not discharge the obligation of the insured to
Kentucky Diagnostic Center except to the extent of payment actually made by the
insurer to Kentucky Diagnostic Center.
5. Allows Kentucky Diagnostic Center to release pertinent medical information to insurer
or other payor to substantiate any and all claims. In addition, it allows Kentucky
Diagnostic Center to release pertinent medical information in order to comply with
utilization review requirements of the payor.
6. This form also allows Kentucky Diagnostic Center to release pertinent medical
information to ancillary medical providers when that request is made in conjunction
with your medical treatment.
7. I also understand that if my insurance carrier requires prior authorization or
precertification for magnetic resonance imaging (MRI) and/or computed tomography
(CT) studies, and it has not been obtained for this MRI/CT and my insurer will not pay
for it, I fully authorize the performance of the exam and realize that I accept full financial
responsibility for the services rendered on this date.
8. By signing my name below, I acknowledge that I have been provided with a Notice of
Information Practices that provides a description of how my medical information will be
used or disclosed.
(Guarantor Name if Different)
This assignment is made for valuable consideration. The payment of any monies to the insured subsequent to
your receipt of the assignment, whether by intent or inadvertence does not discharge your responsibility to
Kentucky Diagnostic Center.