I, the undersigned, authorize payment of medical benefits to Northern Virginia Foot and Ankle Associates/Laurel Foot and Ankle Center for any services furnished to me by the physicians. I understand I am financially responsible for any amount not covered by my health insurance contract. I also authorize you to release to my insurance company any information concerning health care, advice, treatment, or supplies provided to me. This information will be used for the purpose of evaluating and administering claim benefits, including worker comp claims. I permit a copy of this authorization to be used in place of the original.