I hereby consent to any medical treatment, lab procedures, or facility services rendered to me (or to my legal minor) by the medical staff at Medallus Medical. I hereby authorize Medallus Medical to release to my insurance carrier(s), my employer, Social Security Administration (for Medicare / Medicaid patients), and any person or corporation which is liable under a contract to Medallus Medical, all or any part of my medical record for services rendered at Medallus Medical. I agree to be responsible for full payment of all charges incurred at Medallus Medical. I agree to pay my co-pay at the time of service. In case I have no insurance, I agree to pay in full at the time of service. Any unpaid balance after insurance benefits are applied may be referred to an attorney for consideration of alternative payment options. All accounts will be charged an interest rate of 18% per annum until paid in full (1.5% per month The undersigned agrees to pay a service charge of $25 for each check or instrument tendered but returned unpaid. In the event any balance is not paid as agreed, the undersigned agrees to pay a collection fee not to exceed 30% of the unpaid balance, as allowed by Utah Code Annotated, sec. 12-1 11. In the event a lawsuit is brought to collect the unpaid balance, the undersigned further agrees to pay all other costs of collection, court costs and reasonable attorney fees, in addition to, the collection fee. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual whom I have legal responsibility whether such amount(s) are incurred today or after today. I assign and transfer to Medallus Medical all insurance benefits payable to me by my insurance for services and costs incurred in connection with services rendered at Medallus Medical. I will contact the clinic for any appointment cancellation prior to 24 hours of my appointment. I agree to be billed and pay a $20 no-show fee or same day cancellation if I fail to show up for my scheduled appointment.