GASTRCOARE LI RESERVES THE RIGHT TO MODIFY THE PRIVACY PRACTICES OUTLINED IN THE NOTICE

Verification of Family / Friend

The undersigned hereby assigns all monetary benefits to be received by me from any individual, insurance company, or other person or organization as a result of any medical treatment or related services rendered to me by GastroCare LI, partial or full payment directly to GastroCare LI of such benefits.

I also authorize the release of any medical or other information necessary to process claims, I authorize payment of medical benefits to GastroCare LI physicians or suppliersfor all services rendered to me using “SIGNATURE ON FILE”. I request that payment of authorized Medicare benefits be made either to me or on my behalf to GastroCare LI for services furnised to me by the provider
I authorize any holder of medical information about me to release to the Health Care Financing Admininistration and its agents any information needed to determine these benefits of the benefits payable for related services.

This agreement is applicable to all services rendered by GastroCare LI at any future date so long as I do not cancel this agreement in writing.

Due to the ever-changing coverage of insurance plans, in order to accommodate all our patients, we will continue to participate with many managed care plans. However, you
are responsible for knowing the benefits and exclusions of your plan. It will be your responsibility to provide us with complete and accurate insurance information. As always, we will file the claim, but any procedure not covered by
your plan will be your responsibility.

Thank you in advance for your anticipated cooperation in this matter