Financial Policy, Assignment Information, and Release of Information – I authorize the release of any information acquired during treatment necessary to complete & file medical claims to my insurance company on my behalf. I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account I am acting as guarantor. I authorize (assign) any insurance to be paid directly to Pearl Pediatric Clinic or its assignees. I am responsible for any non-covered services, supplies, co-payment, co-insurance or deductibles. I am responsible for knowing how my plan works, and I request medical services at this office. This is acceptable & assignment will be in force for all future services by practitioners from this office.