ASSIGNMENT AND RELEASEI, the undersigned certify that I (or my dependent) have insurance coverage with Type a label and assigned directly to Dr. Navneet Kaur all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
IN CASE OF EMERGENCY, CONTACT (Specify someone who doesn't live in your household)