TO BE SIGNED AND DATED IN OFFICE AT TIME OF APPOINTMENT:
I certify that I, and/or my dependents have insurance with the aforementioned insurance company above, and assign directly to Dr. Robert Dixon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. Dr. Robert Dixon may use my health care information and may disclose such information to the above-named insurance company or companies and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. I understand that I am financially responsible for all charges incurred on the patient's account, whether or not paid by insurance. If this account is turned over to collections, I hereby agree to pay all charges including, but not limited to, cost of collection, court costs, and reasonable attorney fees.