Authorization to release information: I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released nor or in the future.
Authorization to pay Benefits to Physician: I hereby authorized and direct my insurance company to pay Amerejuve Dermatology any medical benefits which would be payable to me for their services.
I understand I am financially responsible for the charges not covered by this authorization.
Authorization for Medical Treatment: I authorize you to give me reasonable and proper medical care by today’s standards.