Assignment of Insurance Benefits and Authorization to Release Information related to Medical Services provided I, hereby, assign all benefits to Paul D. Corona MD, For services rendered to me or said minor patient, I authorize any holder of medical information about me or said minor to release to my insurance company any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made to Paul D. Corona MD, and authorize release of medical information necessary to pay the claim. I have given all my insurance information for billing purposes and understand the billing procedures. I understand that I am responsible for all charges not covered by my insurance policy including, but not limited to: co-payments, deductibles, and non-covered services. A $15 fee will be assessed or any additional statements needed to collect my balance. I agree to complete all necessary paperwork in order for my claim to be paid by my insurance company and accept full responsibility for all charges if payment is not made on my behalf of my insurance company. I understand I will be responsible for all collection fees in the event that my account is not paid in full.
I have been informed and understand that I will be charged $60.00 for missing an appointment without giving 24-hrs notice.