Consent to Examination • Authorization to Release Information • Assignment of Benefits • Financial Agreement
I hereby authorize the above physician to perform a consultation and examination, and to initiate diagnostic and therapeutic treatments that may be considered
advisable or necessary. I hereby authorize the above physician to release to the insurance company or its representative, any information including the diagnosis and
the records of any treatment or examination rendered to me during the period of such medical or surgical care. I hereby give lifetime authorization for payment of
insurance benefits to be made directly to the physician rendering service. I understand that I am financially responsible for all charges whether or not they are
covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize these physicians to release all
information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.