Patient’s or Authorized Person’s Signature
I the undersigned give my authorization to treat and assign directly to Nilesh Patel MD, all medical benefits, If any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not . I hereby authorize the doctor to release all information
paid by insurance this includes deductibles, co-insurance and copayments
necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is expected at the time of service and diagnostic testing is a separate charge from the office visit.