Assign Medicare BB Benefits

Patient Name: Doctor Name:

Date of Service:

Time of Service:

Item Number:

Benefit Amount:

Signature:

Agreement & Declaration: By signing, I, The Patient, agree to assign my Medicare benefit (or that of the person for whom I am legally authorised to act, such as child) for these services to The Doctor at Dundas Street Medical Clinic.
Benefit Item Number : 0.00
Incentive Incentive : $0.00
Total : $0.00
I acknowledge that Medicare will pay the doctor directly and I will not be charged for these services.