If someone other than the patient is responsible for the payment, complete below.
As a patient, or as a legal guardian of minor patients, I agree to pay for all services rendered. This office may bill my insurance carrier as needed.
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ASSIGNMENT & RELEASE: I hereby assign my insurance benefits to be paid directly to SHYAM K. Nair/W.C.M.C. I am financially responsible for non-covered services, I authorize the physicians to release any information necessary to process this request.
I hereby authorize SHYAM K. Nair/W.C.M.C. to release all medical information to the above-named insurance carrier (or to a designated attorney) for purposes of claims administration and evaluation, utilization review and financial audit. This authorization remains valid and effective from the date of signing until revoked in writing. I understand that I may request a copy of this authorization. I have read this authorization and understand it. I hereby assign to Dr. Clifford Segil all money to which I am entitled for medical and /or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physician and /or surgeon. It is understood that any money received from the above named insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible to said doctor for charges not covered by this assignment. I further agree in the event of non-payment, to bear the cost of collection, and /or Court cost and reasonable legal fees should this be required.
Thank you for your submission!