Assignment of Benefits and Release of Information-Financial Agreement:
I hereby give lifetime authorization for payment of insurance benefits be made directly to Marla Kushner, DO and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and any reasonable attorney's fees. I hereby authorize the healthcare provider to release all information necessary to secure the payment of benefits and also authorize the release of any confidential patient information to assist in treatment. I further agree that a photocopy of this agreement shall be valid as the original.
Your information will be encrypted.