I hereby instruct and direct my insurance company to pay by check made out and mailed to this clinic the professional or medical expense benefits allowable, and otherwise payable to me under current insurance policy as payment towards the total charges for the professional services rendered by this clinic. A photocopy of this assignment shall be considered as effective and valid as the original.
RELEASE OF INFORMATION:
I authorize this clinic to release any information relevant to my case to any insurance company adjuster and attorney involved in this case and hereby release this clinic to any consequences thereof.
I agree to be financially responsible for all charges incurred at this clinic including my insurance deductible, co-payment and any services rejected by insurance company.