AUTHORIZATION
I request and give consent to Dr. Drell to provide psychiatric services as are considered necessary or beneficial for my health and well being. My choice is voluntary and I understand that I may terminate therapy at anytime. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me. I hereby authorize Dr. Drell or his staff to furnish information to insurance companies, utilization review companies, and EAP's concerning my evaluation/treatment. I hereby irrevocably assign to the doctor all payments for medical services rendered, unless I have paid for the services in full. I understand that I am financially responsible for all charges whether or not covered by the insurance company. I understand that in the event my account becomes delinquent, Dr. Drell may need to forward the information to a credit reporting agency or an attorney for collection assistance. I waive any rights to confidentiality with regard to information that must be divulged in resolving delinquent accounts.