PATIENT REGISTRATION FORM

ASSIGNMENT or BENEFITS: thereby authorize payment of benefits be made directly to toge Family Medicine understand that am financially responsible to Lège Family Medicine for charges not covered by this assignment authorize refund of overpaid insurance benefits where my coverages are subject to coordinationof benefits in the event of default, agree to pay all costs of collection, including reasonable attorney's fees. This authorization will remain in effect until revoked in writing by the undersigned. certify that the above is correct