Physician's Release and Agreement

I hereby authorize payment directly to Lisa M. Nath, MD, LLC of benefits due to me from my Insurance Company otherwise payable to me.  I further authorize the release of any medical information required by my Insurance carrier(s).  A copy of the authorization may be used in lieu of the original.  I authorize the holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.  I request payment of medical insurance benefits either to myself or to the party who accepts assignment.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY THIS AUTHHORIZATION.    

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY FEES INCURRED BECAUSE I DID NOT PROVIDE ACCURATE INSURANCE INFORMATION.

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY CHARGES INCURRED IF MY INSURANCE REQUIRES AN AUTHORIZATION OR REFERRAL AND I FAILED TO PROVIDE ONE.

I UNDERSTAND THAT IF I FAIL TO PAY ANY OUTSTANDING BALANCES, I WILL BE RESPONSIBLE FOR PAYING ANY CHARGES INCURRED REGARDING THE COLLECTION OF THESE FEES.