I hereby authorize and direct the above insurance company to pay benefits due in accordance with the terms of my policy payable to Malibu Medical Corporation, 23661 Pacific Coast Highway Malibu, CA 90265
●I agree to pay all medical expenses not covered by the above named policy.
●I authorize Malibu Medical to release any information needed by the insurance company regarding this claim.
●I understand and agree that it is my responsibility to verify that Malibu Medical is an approved provider for my specific insurance. If preauthorization or provider verification was not obtained, I understand and acknowledge that I am fully responsible for the bill.
●I understand and agree that if it should become necessary for Malibu Medical to pursue collections of my account through a third party, I will be liable for any and all costs associated with the collection process.
●I request payment of insurance benefits be paid directly to the physician listed on the claim.