RELEASE OF INFORMATION: Your patient record may be disclosed, in full or part, to any organization contracted with the South Texas Emergency Care Foundation, Inc. ("Foundation"), physicians, hospitals, insurance companies, Medicare, Medicaid, workers' compensation carriers, or the patient's employer, in accordance with the Texas Open Records Act. ASSIGNMENT OF BENEFITS: If you, or any party liable to you, have entitlement to benefits arising out of any insurance policies, the Foundation shall receive applicable benefits and discharge the insurance company of all obligations. You will remain liable for any balance not covered. MEDICARE: If you identify yourself as a Medicare beneficiary and currently have Part B benefits, the Foundation, retains the option whether or not to accept assignment. If the Foundation accepts assignment the signature below authorizes HCFA (Medicare) to pay any allowable benefits directly to the Foundation. You also agree to pay the Medicare allowable coinsurance, deductible, and remaining balance not covered by Medicare. MEDICAID: I understand that, in the opinion of the Foundation, the services or items that I have requested to be provided to me on the above date may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the Texas Department of Human Services or its health-insuring agency determines the medical necessity of the services or items that I requested and receive.

By re-entering my last name in the field below, I confirm my acceptance of the information in the "Release of Information" section as outlined above.