I certify that the information given by me in applying for payment under my insurance contract
(Including Title XVII of the social security ACT) is correct. I authorize Urgentmed to release to my insurance carrier, employer, and referring physician any information needed including the diagnosis, and records of any treatment or examination rendered to me to process the claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician (s) or organization furnishing the services and authorize such physician or organization to submit a claim to my health insurance carrier (including Medicare) for payment of medical services rendered to me. This authorization and assignment are to be continuing one, remaining in force until revoked in writing by the undersigned. I also understand that any portion of the fee not paid by my insurance carrier/ company (including any deductibles) will become my personal obligation and will be paid promptly by me. I also understand that if my account is placed with an outside collection agency, I will be responsible for any and all collection fees. I understand that any procedures in addition the office visit will incur additional charges, such as x`rays and laboratory work any lab work that will be sent out to an independent/outside laboratory will be billed to me directly by the lab company, and not Urgentmed. I also give my permission to Urgentmed and to the physician(s) furnishing the services for any treatment necessary.