I, the undersigned, authorize payment of medical benefits to Ear, Nose & Throat Consultants, LLC for any services furnished to me by the physicians. I understand I am financially responsible for any amount not covered by my insurance contract. I also authorize you to release to my insurance company information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
I, knowing that I have a condition requiring diagnosis, treatment, or related medical care do hereby consent to such care, medical examination(s), operation(s), procedure(s), therapy sessions, photographs, and/or treatment by my attending physician(s), their assistant(s) or designee(s) as may be necessary in their professional judgment. I further acknowledge that no guarantees have been made to me as to the results of such care, medical examination(s),operation(s), procedure(s), therapy sessions and/or treatment