I hereby authorize Pulmonary Consultants, P.C., to furnish information to insurance carriers concerning my illness, and treatment. I hereby assign to the physicians ALL payments for medical services rendered to myself or dependent. I understand, I am responsible for ANY amount NOT covered by my insurance company. I am responsible for any unpaid amount and agree to pay court cost, including any attorney fees which are incurred in the collection process.
The patient or authorized representative recognizing the need for care consents to ALL or ANY services as ordered by the physicians, including lab procedure, medical treatment, minor or emergency surgical treatment, exam or other services rendered under specific instruction of the physician.