TIMOTHY N. GORSKI, M.D., F.A.C.O.G.
1001 N. WALDROP DR. SUITE 815
ALRINGTON, TX 76012

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I HEREBY AUTHORIZE DR. TIMOTHY GORSKI TO ACT AS AGENT IN BILLING OF ANY HEALTH INSURANCE AND TO RELEASE SUCH MEIDICAL INFORMATION AS NECESSARY FOR PAYMENT OF BENEFITS WITH MY INSURANCE COMPANY.

SIGNED _______________________________ DATE _______________

ASSIGNMENT OF INSURANCE BENEFITS

IN CONSIDERATION OF MEDICAL SERVICES RENDERED OR TO BE RENDERED TO ME, I HEREBY ASSIGN TO DR. GORSKI ALL MY RIGHT, TITLE AND INTEREST IN THE INSURANCE POLICY(IES) AND I HEREBY AUTHORIZE PAYMENT DIRECTLY TO SAID DOCTOR OF THE BENEFITS OTHERWISE PAYABLE TO ME, BUT NOT TO EXCEED THE BALANCE DUE OF THE DOCTOR’S REGULAS CHARGES. I FULLY UNDERSTAND I AM FINCIALLY RESPONSIBLE TO THE DOCTOR FOR ALL CHARGES NOT COVERED BY THIS ASSIGNMENT AND AUTHORIZATION. AUTHORIZATION IS TO REMAIN IN EFFECT UNTIL ALL BENEFITS ARE TO BE PAID BEFORE ANY OTHER CLAIIMS ARE HONORED.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE MEANING AND INTENT OF THE ABOUVE AND ALL QUESTIONS HAVE BEEN SATISFACTORILY ANSWERED. A PHOTOCOPY OF THE AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AND AS VALID AS THE ORGINAL. I ATTEST I HAVE RECEIVED A TRUE COPY.

SIGNED _________________________________DATE ________________