Assignment of Insurance Benefits

ASSIGNMENT OF INSURANCE BENEFITS

I hereby assign and authorize payment of the covered insurance and health care benefits, including all major medical benefits, otherwise payable to me to be made directly to the physician and/or clinical furnishing services to me including, but not limited to, T. Z. Chen, MD. I understand that health insurance providers, and commercial insurance companies, may not cover part of the medical services rendered and I fully understand that I am financially responsible for and agree to pay all charges not paid by my health care coverage.

I authorize the release of medical information as may be required to process the claims for payment of the medical services rendered and it is expressly understood that the right of such information to be privileged is hereby waived.

I have had the opportunity to discuss with the physician or his staff to my satisfaction the nature of the treatment administered and I acknowledge that no guarantees have been made to me as to the results of such treatment. This form has been fully explained to me and I have had the opportunity to ask any questions concerning the charges for the treatment. I am satisfied that I fully understand this assignment and its significance.

A copy of this assignment shall be considered as valid as the original.