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I, the undersigned, assign all insurance or Medicare benefits, to Dr. Michael D. Herrera for any services furnished to me. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize any holder of medical information about me, to release such information to my insurance or the Health Care Financing Administration and its agents to determine the benefits payable for related services. I understand my signature requests that payments be made and authorizes release of medical information necessary to pay the claim. In the event of default in any amounts due, and if this account is placed in the hands of a collection agency, attorney for collections or legal action, I am to pay an additional charge equal to the cost of collection including collection agency, bank returned items charges, attorney fees and court cost incurred.
In Insurance or Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the insurer or Medicare carrier as the full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination or the insurer or Medicare carrier.