Request for Missing Information

I authorize the release of Medical Records or any other information deemed necessary in order to process this or any past or future claim on my
behalf, or on behalf of the patient listed above.

I further agree to assign medical or other insurance/employer payment benefits for services provided. I authorize to appeal payment denial or other adverse decisions on my behalf
without further authorization.

I understand I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and submit it to the Medical Records Department.

I agree to pay any coinsurance, deductible or non-covered service so deemed by my insurance carrier.