Common Contracts
1 similar Payment Guaranty Agreement contracts
PAYMENT GUARANTY AGREEMENT – ASSIGNMENT OF INSURANCE BENEFITS AUTHORIZATION TO RELEASE MEDICAL INFORMATIONPayment Guaranty Agreement • May 13th, 2016
In signing this form I acknowledge that I am responsible for any and all charges incurred as a result of treatment provided to me or my family members by Dr. Henry Morris and associates from the beginning date of service shown above. I understand that this is done only as a courtesy and I am fully responsible for any services not covered by my insurance company. My signature on this form will also constitute authorization for my insurance company to assign benefits directly to Dr. Henry Morris and his associates. I also authorize Dr. Henry Morris and his associates to release whatever medical information necessary in order to file a claim under any insurance policy through which I am covered. Should my account have to be referred for collection, then I agree to pay attorneys fees of 33-1/3% and all costs incurred therein.
