I authorize my insurance benefits to be paid directly to Associates in Women's Health, P.A., for services rendered. I understand that I am financially responsible for all charges, whether or not they are paid by insurance or workmen's compensation. I acknowledge and certify that my information is accurate. I authorize Associates in Women's Health, P.A., to release all pertinent medical information to insurance carriers. A photocopy of the authorization and assignment shall be considered valid as the original.