I request the payment of authorized Medicare or other insurance company benefits be made in my behalf to Orlando Family Medical, Inc. for any services furnished to me by that party which accepts assignment/physician regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries of carriers any information needed for this or a related Medicare claim /other insurance company claim. I authorize Orlando Family Medical to view and obtain external medication reconciliation from other providers. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to me or to the party that accepts assignment. I understand that it is mandatory to notify the health care provider of any other party that may be responsible for paying for my treatment (Section 1128B of the Social Security Act and 31 U.S.C. 38/01-3812 provides penalties for withholding this information.)I request that payment under the Medicare or other medical insurance program(s) be made to Orlando Family Medical, Inc. for as long as I continue to receive services from them. If I were to receive any checks (payments) intended as payment for services rendered by Orlando Family Medical, Inc. from Medicare or other insurance company(ies), I will immediately endorse them and turn over to Orlando Family Medical, Inc. for services rendered. I understand that I am responsible for payment of all charges and fees to Orlando Family Medical, Inc. to which they are entitled to collect which are not paid by Medicare or any other insurance.