PLEASE READ & SIGN: I understand that it is my responsibility to pay any applicable co-payments, deductibles, co-insurance, and any other balance not paid for by insurance. I understand that it is my responsibility to obtain a valid referral, if applicable, for all visits and if any claim is denied for no referral then I may be responsible for payment. I understand that it is my responsibility to advise the practice of any changes to any of the above information and if any claim is denied as a result of not advising the practice then I may be responsible for payment. I hereby authorize the doctor and/or the practice to release all information necessary to secure the payment of benefits. I authorize and assign all benefits to be paid directly to the practice. I agree that a photocopy of this agreement shall be as valid as the original.

PLEASE READ & SIGN:I understand that it is my responsibility to pay any applicable co-payments, deductibles, co-insurance, and any other balance not paid for by insurance. I understand that it is my responsibility to obtain a valid referral, if applicable, for all visits and if any claim is denied for no referral then I may be responsible for payment. I understand that it is my responsibility to advise the practice of any changes to any of the above information and if any claim is denied as a result of not advising the practice then I may be responsible for payment. I hereby authorize the doctor and/or the practice to release all information necessary to secure the payment of benefits. I authorize and assign all benefits to be paid directly to the practice. I agree that a photocopy of this agreement shall be as valid as the original.

PATIENT SIGNATURE:

DATE: