I authorize the above-named doctor/clinic to furnish to the above named attorney all information provided by or pertaining to me, including all records relating to the above-named doctor's/clinic examination, diagnosis, treatment, prognosis, etc.
I authorize and direct the above-named attorney to withhold from any disability, medical, no-fault, health, accident, worker's compensation benefits, or any other benefits, insurance or reimbursement which may be payable to me or for my benefit arising from the condition for which I have been treated or received services, any amount as may be necessary to pay for such treatment or service, and to pay any amount which may be due and owing to the above-named doctor/clinic.
Responsibility for Payment
I agree that I am personally responsible for prompt payment to the above-named doctor/clinic of all amounts that may be due and owing for treatment or services rendered to me for my benefit, that payment shall not be contingent upon the payrnent upon the payment to me of any benefit, insurance or reimbursement by any other party, and that the lien and direction to pay contained in the preceding paragraph is solely as additional security to the above —named doctor/clinic.
Cost of Collection
I agree that if any amount due and owing to the above-named doctor/clinic for treatment or services performed for me is not paid when due, interest collection costs, including attorney fees, will be added to the amount due.
I specifically waive any claim of privilege with respect to the disclosure by the above-named doctor/clinic to the above-named attorney of information provided by or pertaining to me, which I specifically authorize to be disclosed.