Assignment of Insurance Benefits

I hereby authorize direct payment of surgical and/or medical benefits to Dr. Debora Sedaghat, D.O., for services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance(s) not covered by my insurance. I further agree, in the event of non-payment, to bear the cost of reasonable legal fees, should this be required.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.