Social Security No.:
Emergency Contact Name:
Emergency Contact Phone:
Assignment of Benefits and Release of Information-Financial Agreement:
I hereby give lifetime authorization for payment of insurance benefits be made directly to Marla Kushner, DO and any assisting physicians or services rendered, I understand that I am financially responsible for all changes
whether or not they are covered by insurance. In the event or default, I agree to pay all costs of collection, and any reasonable attornet's fees. I hereby authorize the healthcare provider to release all information
necessary to secure the payment of benefits and also authorize the release of any confidential patient information to assist in treatment. I further agree that a photocopy of this agreement shall be valid as the original.
Marla Kushner, DO