FAMILY PRACTICE
12345 Maple Drive
AnyCity, Florida 33000
Phone: 977-123-4567
Fax: 977-1234568

RELEASE OF INFORMATION AND DIRECTION TO PAY

______________________________________________________

I hereby authorize John Smith, M.D., PA to release any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.

I hereby instruct and direct the insurance company to pay John Smith, M.D., PA directly and mail it to the address above.

If my current policy prohibits direct payment to the physician, then I hereby instruct and direct you to make the check payable to me and mail it as follows:

I understand that I am directly responsible to John Smith, M.D., PA for all medical bills and understand that such responsibility is not contingent on any insurance policy, settlement, judgment or verdict by which I may eventually recover said fee.

This agreement is NOT revocable and cannot be changed unless proof of payment in full of the physician's bill is provided to you.

A photocopy of this Assignment shall be considered as effective and valid as the original.

Date: _________________

Patient's Signature: ____________________________________

Witness: _____________________________________