ASSIGNMENT OF BENEFITS/AUTHORIZATION TO RELEASE INFORMATION TO THE ABOVE INSURANCE COMPANIES

I hereby authorize all medical and/or surgical benefits to Scott Sanders MD PLLC. This includes all major medical benefits, Medicare /Medigap, HMO and Government sponsored programs, or any other third-party payor for services rendered to me. I understand that I am responsible for all applicable DEDUCTIBLES, COPAYMENTS, COINSURANCE AND NON-COVERED SERVICES as required by my insurance policy.

I hereby authorize Scott Sanders M.D. PLLC to release all information necessary, including medical
records to secure the payment of insurance benefits.

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

MEDICARE ONLY

By signing below, I provide authorization for Medicare to assign benefits to my physician, Scott Sanders MD PLLC.

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