Insurance Assignment and Authorization to Release Information

1. Release Of Information - I, the below named patient, do hereby authorize any physician examining and/or treating me to release to any third party payer (such as an insurance company or governmental agency, example: Blue Cross Blue Shield of Florida or Medicare) any medical and psychiatric information and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment and/or diagnosis. I specifically consent to the release of any material in your possession, including, if any exists, results of HIV (AIDS) tests, and any which might address chemical dependence, depression, or other psycho emotional issues.

2. Physician Insurance Assignment - I, the below named subscriber, hereby authorize payment directly to any physician examining or treating me of any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charge for these services.

3. Medicare/Medicaid - Patient's certification/authorization to release information and payment request. I certify that the information given by me in applying for payment under title XVII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration Division of Family Services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to the treatment shall be assigned to the physician treating me.

4. I permit a copy of these authorizations and assignments to be used in place of the original which is on file at the physicians' office. I agree that should the amount of the insurance benefits be insufficient to cover the expenses, I will be responsible for payment of the difference. I will be responsible for the entire amount due for professional services rendered if the expense is not covered by my policy.

Date:_________________Subscriber Signature:________________________________________
Patient Signature:__________________Responsible Party Signature:_______________________
Original Signature On File At Physicians' Office