I hereby authorize the above physician to perform an orthopedic consultation and examination, and to initiate diagnostic and therapeutic treatments that may be considered advisable or necessary. I hereby authorize the above physician to release
to the insurance company or its representative, any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I hereby give lifetime authorization for
payment ofinsurance benefits to bemade directly to thephysicianrendering service.I understand that I am financially responsible for all charges whether or not they are covered by insurance. Inthe event ofdefault, I agree topay all costs of
collection, and reasonable attorney’s fees. Ihereby authorizethese physicians toreleaseall information necessary tosecure thepayment ofbenefits.Ifurther agree that aphotocopy ofthis agreement shall beas valid as theoriginal.