I hereby assign, transfer and set over to Allergy & Asthma Medical Associates, Ltd. dba Relief Allergy & Sinus Institute (the “Practice”) all my rights, title, and interest in my medical reimbursement benefit under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. (Charges may include any service charges, collections fees, late fees and bad check handling charges). You will be required to also sign our Patient Financial Responsibility Agreement which outlines further financial responsibilities.
I understand that presenting myself (or my legal guardian) for health care services at the Practice, I authorize and consent to the performance of all tests, treatments and procedures which may be ordered by my physician(s) or providers and I consent for such treatments and procedures to be carried out by members of the medical and nursing staff at the Practice.