Common Contracts
1 similar null contracts
REGISTRATIONOctober 2nd, 2017
and assign directly to Dr. all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
