ASSIGNMENT AND RELEASE:
· I hereby assign my insurance benefits to be paid directly to the physician
· I understand that I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered or not exempted under the terms of my health plan.
· I authorize the physician to release any medical information required to process this claim.
· I authorize my provider’s office to conduct telehealth visits when necessary.
· I consent to have COVID-19 testing performed.