I hereby authorize and direct the above named practice, having treated me to release to governmental agencies, insurance carriers, or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and permit representative therefore to examine and make copies of records relating to such treatment. Upon request for release of records, I hereby authorize Garden City Dermatology, PC to furnish all records and results to the parties I specify. I hereby assign, transfer and set over the above named practice sufficient monies and/or benefits to which I may be entitled from government agencies, insurance carriers, or others who are financially liable for my medical cost of care and treatment rendered to myself or my dependent in said practice. I agree to pay all monies, including the full original fee, all $20 administrative fees and 1.5% monthly interest so that Garden City Dermatology receives full reimbursement of monies due. I acknowledge that the information provided above is accurate. The following will result in you being held responsible for full payment regardless of your insurance contracts: if you provide inaccurate/incomplete insurance information, if your plan requires a referral and you do not secure one, if your plan requires that you be seen by an in network provider and our providers are not defined as such with your insurance carriers. I understand that I am responsible for any and all services not covered by my insurance company. I accept responsibility for payment of my account.