To the best of my knowledge, all of this information is true and complete. I understand that I am responsible to pay for all services rendered to me. I am willing to make specific arrangements to pay any part not covered by insurance on a timely basis. A photocopy of this assignment is to be considered as valid as the original. If I am a Medicare beneficiary, I request that payment of authorized Medicare benefits be made directly to the practice, for any service provided me by the practice’s providers.