I authorize my insurance benefits to be paid directly to the physician and I agree to be financially responsible for all charges incurred. I hereby consent to the release and redisclosure of my medical records to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third-party payer, HMOor other health benefit plan. This consent applies to Altmed or any of its affiliates. I agree to pay for service rendered to me or the above-named patient at the time of services or the first statement mailed by Altmed. I promise to pay my account when due and should this account become delinquent and collection becomes necessary, the undersigned agrees to be responsible for attorney's fees of thirty-three and one third percent (33 1/3%), interest at eighteen percent (18%) per annum from the last date of payment and any and all applicable court costs. I further agree to pay for my any reasonable fees for missed appointments of which I did not notify the medical office at least 24 hours prior to your appointment.
In the event that a check is returned for insufficient fund you are responsible for $35.00 return fees. I {name}as the financially responsible party to the above-named patient agree to the aforementioned statements and authorize payment of medical benefits to Altmed for services rendered.