I hereby assign and authorize payment directly to the North Carolina Department of Health and Human Services. Division of Mental Health Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) or any hospital benefits, sick benefits, injury benefits due because of liability of a third-party, or proceeds of all claims resulting from the liability of a third-party, organization, etc. to or for the client unless the account for this inpatient/residential outpatient treatment or series of outpatient treatments is paid in full upon discharge or completion of outpatient treatments. If eligible for Medicare, I request Medicare Services and benefits. I further agree that this assignment will not be withdrawn or voided at any time until my account balance is paid in full. I understand that I am responsible for any charges not covered by my Insurance company. The undersigned individually obligates himself to pay the account balance in accordance General Statues. Article 7 143-117 and 143-118.