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DOB: 

I hereby authorize my insurance carrier, attorney, or any third-party payer to pay directly to Southwest Internal Medicine Specialists all charges submitted for services incurred by me. I understand I will be responsible for any and all charges not paid by my insurance company. I authorize Southwest Internal Medicine Specialists to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the physicians at Southwest Internal Medicine Specialists which may be due from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or part medical services which I have received. The authorization and assignment shall be valid until I notify Southwest Internal Medicine Specialists in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.

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