I, the undersigned, certify that I (or my dependents receiving services) have insurance coverage as noted above and assign all insurance benefits otherwise payable to me for services rendered to be payable directly to NewSouth NeuroSpine, LLC (NS2). I understand and agree that I am financially responsible for all charges for services rendered to me (or my dependents) including those that may or may not be covered by an insurance plan in (with) which I participate. I understand that while others may also be responsible for paying these charges by virtue of an express or implied agreement, or otherwise, I am responsible for paying all charges. I understand that payment of all co-insurance, co-pays, and deductibles is preferred at the time services are rendered and that payment can be made by Visa, Mastercard, American Express, Check, Money Order, or Cash. I understand that if I fail to pay for my charges and NS2 refers my account to an attorney or collection agency, I am also responsible for all fees that such attorney or collection agency may charge. I hereby authorize NS2 to release all information necessary to secure payment for services provided. I authorize the use of my signature on all insurance submissions for these services. I authorize NS2 to release my (or my dependent's) medical records to referring, primary care, and/or treating physicians and applicable diagnostic centers.