It is your responsibility to pay any deductible amount, co-insurance, or any balance not paid for by your insurance. I request that payment of authorized insurance benefits be made on my behalf for any services furnished to me. I authorize any medical information about me to be released to the Health Care Financing Administration, its agents, or any insurance carrier I may have, including any information needed to determine these benefits or the benefits payable for related services. I understand that I am financially responsible for all charges whether or not paid by said insurance. This assignment will remain in effect until revoked by me in writing.