I hereby authorize my insurance company, including Medicare if I am a Medicare Beneficiary, to make payments to Alabama Ear, Nose & Throat Specialists, LLC (ALENTS) for medical or surgical services or items rendered to me or my dependent by ALENTS. Should my insurance carrier deny ALENTS, I understand that I am financially responsible for the charges. I authorize ALENTS to release any and all of my records to my insurer, or any other third party payer, legally responsible for the payment of medical expenses. Should failure to pay for medical services result in my account being turned over for collection from a third party, or my insurer, I understand that I am responsible for the account balance plus reasonable collection and/or attorney's fees. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance and health information.