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  ASSIGNMENT AND RELEASE

I understand that I am financially responsible for all services received whether or not paid by my insurance. I certify that I, and/or my dependent(s) have insurance coverage and assign directly to
Dr. Walton K. Joyner Jr. M.D. All insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to my Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

______________________________________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
 
Name of Patient, Parent, Guardian or Personal Representative
Last Name:     First Name:  
 
Relationship to Patient