Get Authorization To Bill Health Insurance/assignment Of Benefits - Titus ...

This guide provides clear instructions on how to fill out the Authorization To Bill Health Insurance/Assignment Of Benefits - Titus form online. Follow these steps to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient’s name in the designated field at the top of the form. Ensure that the name matches the individual receiving treatment.
3. Enter the patient’s Social Security number in the specified field. This information is used for identification and billing purposes.
4. Input the patient’s date of birth in the correct format. This is critical for verifying the patient's identity and eligibility.
5. Review the specific authorizations listed in the form. Check the appropriate boxes to indicate your permissions regarding communication and the use of protected health information.
6. Read the section about the expiration of authorization. This informs you that the authorization can expire upon your request.
7. Make note of your right to revoke authorization. If needed, ensure you understand how to do this in writing.
8. In the section for the patient's signature, provide your name, date, and signature or the signature of a legal guardian if applicable.
9. If applicable, have the personal representative sign in the 'FOR OFFICE USE ONLY' section and specify their authority.
10. Once you have filled out the form completely, save any changes made. You can then download, print, or share the completed form as required.

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