We require insured patients to complete assignment of benefits authorizing insurance to remit payment to the physician's office. I hereby assign all medical benefits to include major medical benefits to which I am entitled, private insurance, and any other health plans to: Women’s Health and Wellness Clinic, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges where or not paid by said insurance. I hereby authorize said assignee to release all medical information necessary to secure the payment.