I hereby authorized my insurance carrier to pay medical benefits directly to Sparks Family Medicine, Ltd. I authorize Sparks Family Medicine, Ltd. to release any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS confidential information, acquired in the course of my treatment necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities. I understand that I am financially responsible for all charges made to my account whether or not an insurance company is involved in payment. I am further responsible for all co-payment, co-insurance amounts, non-covered supplies and services, and yearly deductibles. I am also responsible for collection fees incurred by Sparks Family Medicine, Ltd. in efforts to receive payment of my financial obligations for services rendered. A photocopy of this authorization is to be considered as valid as the original, until revoked by me in writing.