I hereby assign all medical and/or surgical benefits to which I am entitled including private insurance and any other health plans to Family Practice Associates. This Assignment will remain effect until revoked by me in any wrong. A photocopy of this assignment is to be
considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure payment. I understand that I am Financially Responsible for all charges not paid by my Insurance Carrier. In an effect to continue to deliver the highest quality of care on which you have come to rely, we can wither curtail services or attempt to collect cost. We have chosen to pursue the latter option. With that in mind, we trust we can depend on your cooperation.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Family Practice Associates or insurance company to release any information required to process my claims.