...KEY COLUMNS... I hereby authorize and consent to examination and treatment as deemed necessary by physicians of Medical Group, Inc. CRLF
I authorize release of information to my insurance carrier should it be necessary. CRLF
The undersigned agrees to pay any costs incurred by Medical Group, Inc. in the event of account delinquency, all amounts due including, but not limited to, reasonable attorney’s fees. CRLF
I hereby assign all medical and/or surgical benefits, including major medical benefits to which I am entitled, including Medicare, private insurance and other health plans to Medical Group, Inc. CRLF
This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as the original. CRLF
I further authorize the release of all information necessary to secure payment. I understand and agree that payment by the responsible party will not be delayed or withheld because of any dispute between the responsible party and any insurance company, reimbursing agency, third party payer or because of pending legal claims. CRLF