M-CL-0327-AA 0616A Physicians Mutual Insurance Company Claim Services PO Box 2018 Omaha, NE 68103-2018 Fax: 1-402-633-1020 provider.physiciansmutual.com Assignment of Benefits Date Policy Number I, , authorize payment of benefits to this Provider of Services: Provider Name Provider Address City State ZIP Provider Phone Number Provider Social Security Number/Tax ID Number X Policyowner’s/Power of Attorney’s Signature
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
M-CL-0327-AA 0616A
Physicians Mutual Insurance Company Claim Services PO Box 2018 Omaha, NE 68103-2018 Fax: 1-402-633-1020 provider.physiciansmutual.com
Assignment of Benefits
Date
Policy Number
I, , authorize payment of benefits to this Provider of Services:
Provider Name
Provider Address
City State ZIP
Provider Phone Number
Provider Social Security Number/Tax ID Number
X
Policyowner’s/Power of Attorney’s Signature
Related Documents
