I hereby authorize direct payment of surgical/medical benefits to Herbert A. Insel, MD. For services by him in person or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance (ie, deductible, co-insurance, copay).
I hereby authorize Herbert A. Insel, MD to release any medical or incidental information that may be necessary for either medical or in processing applications for financial benefit.
I hereby certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be valis as original.