The above information is accurate to the best of my knowledge.
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled, to CNY Family Care, LLP. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health / medical plan to issue payments directly to CNY Family Care, LLP for medical services rendered to myself and / or my dependents. I understand that I am personally financially responsible for any amounts not covered by insurance. This assignment shall remain in place until I revoke it.