I authorize use of this form on all my insurance submissions.

I authorize release of information to all my insurance companies.

I understand that I am responsible for my bill id the insurance company does not pay for any reason.

I authorize my doctor to act as my agent in helping me obtain payment for my insurance companies.

I authorize payment direct to my doctor.

I permit a copy of this authorization to be used in place of the original.

I agree to pay all fees plus prevailing interest if I am taken to collections for unpaid bills.