Assignment and Release: 1. I hereby assign my insurance benefits to be paid directly to the physician; or, if my current policy prohibits direct payment to
the doctor, I instruct and direct my insurance company to make out the check to me and the rendering physician. 2. I also authorize the physician to
deposit checks received on the patient's account when made out to the patient. 3. I also authorize the physician to release any information
required to process claims or required in the course of my exam and treatment. 4. I hereby agree to pay my account as services are provided. If for any
reason there is a balance owing on my account, I agree to pay promptly upon receipt of the monthly statement. 5. I authorize my rendering physician to
initiate a complaint to the Insurance Commissioner for any reason on my behalf.