I hereby assign all medical benefits and hereby authorize my insurance carrier, including Medicare, private insurance, and any health plan, to issue payment(s) directly to Restoration Integrated Health for medical services rendered to myself and/or my dependents. I understand that I am ultimately responsible for any amount(s) not covered by insurance. I hereby authorize Restoration Integrated Health to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims, pursue appeals on denied or partially paid claims that are generated in the course of examination or treatment. A photocopy or scan of this document is considered as valid as the original. This order will remain in effect until revoked by me in writing.