ASSIGNMENT OF BENEFITS/AUTHORITY FOR RELEASE OF INFORMATION:

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I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Lawall for any covered services furnished to me by this facility. I authorize the release of any information necessary to provide services or process claims. Even though your insurance company authorizes services, an authorization is not a guarantee of payment. As the responsible party I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited or non-existent. I agree to notify Lawall immediately of any change in insurance coverage or status. The date of service that will be billed to your insurance company is the date the device. is received.