Date
IS VISIT A RESULT OF AN ACCIDENT YESNO
SEX FM
AUTHORIZATION: I HEREBY AUTHORIZE THE PHYSICIAN INDICATED ABOVE TO FURNISH INFORMATION TO THE INSURANCE CARRIERS CONCERNING THIS ILLNESS/ACCIDENT, AND I HEREBY IRREVOCABLY ASSIGN TO THE DOCTOR ALL PAYMENTS FOR MEDICAL SERVICES RENDERED. I UNDERSTAND THAT IAM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT COVERED BY INSURANCE.
