A. I hereby authorize release of any medical information necessary to evaluate my case or process any future claims. B. I authorize payment of any medical benefits from third parties for any future charges submitted to be paid directly to this office We invite you to discuss with US any questions regarding our services and or fees. The best health services are based on a friendly, mutual understanding between the provider and patient.
Iunderstand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my medical or insurance status.