INSURANCE ASSIGNMENTS AND AUTHORIZATIONS

1. RELEASE OF INFORMATION: I, the below named patient or guardian, do hereby authorize any physician examining and/or treating me to release to third payer (such as insurance company or governmental agency) any medical, psychiatric condition, alcohol or drug related condition and records concerning diagnosis and treatment when requested by such third party for its use in connection when determining a claim for payment for such treatment and/or diagnosis.

2. PHYSICIAN INSURANCE ASSIGNMENT: I, the below named subscriber, hereby authorize payment directly to the physician examining or treating me of 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. I PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENT TO BE USED IN PLACE OF THE ORIGINAL THAT IS ON FILE AT THE PHYSICIAN’S OFFICE. This assignment will remain in effect until revoked by me in writing.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. I understand it’s my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by my insurance or third payer within a reasonable period of time not to exceed 90 days.

If this account is assigned to an attorney for collections, the prevailing party shall be entitled to reasonable attorney fees and cost of collections.

I have read and understand the Office Policies for Dr. Amit Vijapura and Associates.

Patient’s signature: _____________________________ Date: _________________

Guardian’s signature: ____________________________ Date: ________________