INSURANCE AUTHORIZATION AND RELEASE:

I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered to me or my dependents during the period of such care to a third party payers (insurance) and/or other health practitioners as requested.

I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that the patient responsibility is due at the time of service. Any co-pay and past due balance must be paid at the time of service.

By signing this form, I accept and agree to these polices. My signature indicates my consent to treatment for myself or my dependent. I give consent for the doctor to request my medication prescription history from pharmacies for continuity of care.