To the best of my knowledge, all of this information is true and correct. I understand that I am responsible to pay for all services rendered to me and that I am willing to make specific arrangements to pay what is not covered by insurance on a timely basis. (PLEASE REMEMBER THAT INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT FOR FEES PAID TO THE DOCTOR AND IS NOT A SUBSTITUTE FOR PAYMENT.) I grant permission to my physician to mutually exchange medical information with my referring physician(s) and/or their associates. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient’s medical record to my insurance and Medi-gap carriers. If this account is assigned to an attorney for collections and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection. I hereby assign all medical benefits to which I am entitled to my physician for services rendered to me or my dependent. This assignment will remain In effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I request that payment of authorized Medicare, Medicaid, and/or other insurance benefits be made directly to HIGHLANDS ONCOLOGY GROUP for any service provided to me by HIGHLANDS ONCOLOGY GROUP. I authorize HIGHLAND ONCOLOGY GROUP to release information to HCFA and its agents any information needed to determine benefits.