I hereby authorize payment of medical benefits billed to my insurance by ASTRA BH. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I agree to provide ASTRA BH with the most current and up-to-date insurance(s) information within 30 DAYS of any changes to my insurance information; to include losing insurance and transitioning into a self-pay status. I accept responsibility for fees that exceed the payment made by my insurance, and/or if ASTRA BH or the provider do not participate with my insurance. I hereby authorize ASTRA BH to use and/or disclose my health information, which specifically identities me or which can reasonably be used to identify me, to carry out my treatment, payment, and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign this consent, the ASTRA BH can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that ASTRA BH provider took before receiving my revocation.