FOR MEDICAL CARE AND ASSIGNMENT OF BENEFITS
provide consent for all medical care and assign all medical and/or surgical
benefits, to include major medical benefits to which I am entitled, private
insurance, and any other health plan to Allen Family Clinic, PA. and Frisco
Family Clinic. This assignment will remain in effect until revoked by me in
writing. A photocopy of this assignment is considered as valid as an original.
I understand that I am financially responsible for all charges whether or not
paid by said insurance. I hereby authorize said assignee to release all
information to secure the payment.